MOLECULAR GENETICS OF ACUTE INTERMITTENT PORPHYRIA · More detailed information about heme biosynthesis is available in the literature (e.g. Moore et al. 1987, Kappas et al. 1995)

MOLECULAR GENETICS OF

ACUTE INTERMITTENT PORPHYRIA

IN FINLAND

SAMI MUSTAJOKI

Helsinki 1999

Division of Endocrinology, Department of Medicine, University of Helsinki and

Department of Human Molecular Genetics, National Public Health Institute, Finland

MOLECULAR GENETICS OF

ACUTE INTERMITTENT PORPHYRIA

IN FINLAND

SAMI MUSTAJOKI

To be presented, with the permission of

the Faculty of Medicine, University of Helsinki,

for public examination in auditorium 1,

Meilahti Hospital, on October 29th, 1999 at 12 noon.

Helsinki 1999

Supervisors Raili Kauppinen, M.D., Ph.D.

Department of Medicine, Division of Endocrinology

University of Helsinki, Finland

Professor Leena Peltonen-Palotie, M.D., Ph.D.

Department of Human Molecular Genetics

National Public Health Institute and

Department of Medical Genetics


Reviewers Professor Jean-Charles Deybach, M.D., Ph.D.

Hôpital L. Mourier and Faculté de Médecine X. Bichat

Université Paris 7, France

Professor Marja-Liisa Savontaus, Ph.D.

Department of Medical Genetics

University of Turku, Finland

Opponent Professor Juha Kere, M.D., Ph.D.

Finnish Genome Center


ISBN 951-45-8723-5 (PDF version)Helsinki 1999Helsingin yliopiston verkkojulkaisut

To Ulla

CONTENTS4

CONTENTS

ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ORIGINAL PUBLICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2. REVIEW OF THE LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.1. Heme biosynthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.2. The porphyrias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122.3. Acute intermittent porphyria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2.3.1. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142.3.2. Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152.3.3. Clinical features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.3.4. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182.3.5. Biochemical findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.3.6. CRIM subtypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

2.4. Porphobilinogen deaminase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.4.1. Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212.4.2. Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.5. Molecular genetics of acute intermittent porphyria . . . . . . . . . . . . . . . . . . . . . . . . 232.5.1. The porphobilinogen deaminase gene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232.5.2. Mutations resulting in AIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

3. AIMS OF THE PRESENT STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

4. MATERIAL AND METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314.1. Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314.2. DNA and RNA isolation, and cDNA synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 314.3. DNA amplification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314.4. Subcloning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324.5. Mutation screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324.6. Sequencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334.7. Solid-phase minisequencing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334.8. In vitro mutagenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

CONTENTS 5

4.9. COS-1 cell culture and DNA transfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344.10. Enzyme activity assay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344.11. Western blot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354.12. Pulse-chase and immunoprecipitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354.13. Immunofluorescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

5. RESULTS AND DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375.1. Identified mutations (I, II, III) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375.2. SSCP and DGGE in screening for novel mutations (I, II, III, IV) . . . . . . . . . . . . . 415.3. Monitoring the effect of mutations to allelic transcript levels (V) . . . . . . . . . . . . . 435.4. Expression of mutated polypeptides (III, VI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475.5. Outcome of mutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

5.5.1. Mutations resulting in premature termination codon . . . . . . . . . . . . . . . . . . . 525.5.2. Missense mutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535.5.3. Splicing mutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575.5.4. Other mutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

5.6. Molecular genetics of AIP in the Finnish population . . . . . . . . . . . . . . . . . . . . . . . 615.5. DNA diagnosis of AIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

6. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

7. ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

8. REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

ORIGINAL ARTICLES I-VI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

ABBREVIATIONS6

ABBREVIATIONS

aa Amino acid

AIP Acute intermittent porphyria

ALA Aminolevulinic acid

bp Base pair

BSA Bovine serum albumin

CYP Cytochrome P-450

DGGE Denaturing gradient gel electrophoresis

DNA Deoxyribonucleic acid

dNTP Deoxynucleotide triphosphate

EDTA Edetate disodium tetraacetic acid

IVS Intervening sequence

kb Kilobase

kD Kilodalton

mRNA Messenger ribonucleic acid

PBG Porphobilinogen

PBGD Porphobilinogen deaminase

PBS Phosphate buffered saline

PCR Polymerase chain reaction

RNA Ribonucleic acid

SDS Sodium dodecyl sulfate

SSCP Single-strand conformation polymorphism

Amino acids are abbreviated by one or three letter codes and nucleotides by one letter codes.

ORIGINAL PUBLICATIONS 7

LIST OF ORIGINAL PUBLICATIONS

I Kauppinen R, Mustajoki S, Pihlaja H, Peltonen L, Mustajoki P: Acute intermittent

porphyria in Finland: 19 mutations in the porphobilinogen deaminase gene. Hum Mol

Genet 4:215-222, 1995.

II Mustajoki S, Pihlaja H, Ahola H, Petersen NE, Mustajoki P, Kauppinen R: Three splicing

defects, an insertion, and two missense mutations responsible for acute intermittent

porphyria. Hum Genet 102:541-548, 1998.

III Mustajoki S, Ahola H, Mustajoki P, Kauppinen R: Insertion of Alu element responsible for

acute intermittent porphyria. Hum Mutat 13:431-438, 1999.

IV Nissen H, Petersen NE, Mustajoki S, Hansen TS, Mustajoki P, Kauppinen R, Hørder M:

Diagnostic strategy, genetic diagnosis and identification of new mutations in acute

intermittent porphyria by denaturing gradient gel electrophoresis. Hum Mutat 9:122-130,

1997.

V Mustajoki S, Kauppinen R, Mustajoki P, Suomalainen A, Peltonen L: Steady state

transcript levels of the porphobilinogen deaminase gene in patients with acute intermittent

porphyria. Genome Res 7:1054-1060, 1997.

VI Mustajoki S, Laine M, Lahtela M, Mustajoki P, Peltonen L, Kauppinen R: Acute

intermittent porphyria: expression of mutant and wild type porphobilinogen deaminase in

COS-1 cells. Manuscript submitted.

In addition, some unpublished data are presented.

INTRODUCTION8

Figure 1.1. Heme biosynthesis pathway.

1. INTRODUCTION

Heme is synthesized in every eukaryotic and prokaryotic cell and it carries out many important

biologic functions. It is the prosthetic group of many hemeproteins. The best known function of

heme is its oxygen binding and transport in hemoglobin, and erythroblasts synthesize 85% of

the total body heme is the bone marrow (Berk et al. 1976). In addition, heme is involved in the

mitochondrial respiratory chain where it transports electrons to cytochromes. CYP enzymes,

which metabolize a large number of clinically important drugs as well as several endogenous

and exogenous substances, contain heme. Tryptophan pyrrolase, which catalyses the oxidation

of tryptophan, is also a heme-dependent enzyme.

Porphyrias are defects in heme biosynthesis. The heme biosynthesis pathway contains eight

steps and dysfunction in seven of them is associated with a specific porphyria (Figure 1);

defects in erythroid specific ALA synthase result in X-chromosome linked sideroblastic

anemia.

INTRODUCTION 9

Acute intermittent porphyria (AIP) is caused by a defect in the third enzyme in the heme

biosynthetic pathway, porphobilinogen deaminase (PBGD, also referred to as

hydroxymethylbilane synthase and uroporphyrinogen I synthase, EC 4.3.1.8). It is the most

common type of acute porphyria in Finland (Mustajoki and Koskelo 1976) and in most other

countries (Sassa and Kappas 1981). AIP is characterized by potentially lethal acute attacks with

abdominal pain, tachycardia and various other neuropsychiatric signs and symptoms (Kappas

et al. 1995).

The gene coding for human PBGD was characterized in 1986 (Raich et al. 1986) which enabled

the characterization of the molecular genetic background of AIP. The purpose of this series of

investigations was to identify the molecular defects in Finnish AIP patients and, furthermore,

to elucidate the mechanisms by which a mutation results in the deficient function of the

enzyme.

REVIEW OF THE LITERATURE10

2. REVIEW OF THE LITERATURE

2.1. Heme biosynthesis

All the enzymes and their genes in the heme biosynthetic pathway have been characterized

(Kappas et al. 1995, Nishimura et al. 1995). The biosynthesis pathway is illustrated in Figure

2.1. The first and the last three of the enzymes in the pathway are localized in mitochondria; the

intermediate enzymes are cytosolic. The precursors of heme are glycine and succinyl coenzyme

A which are combined by aminolevulinic acid (ALA) synthase to form 5-aminolevulinic acid

in the presence of the cofactor pyridoxal 5'-phosphate. Next, two molecules of ALA are

condensed to a monopyrrole porphobilinogen (PBG) by ALA dehydratase.

Porphobilinogen deaminase (PBGD) assembles the four rings of PBG in a stepwise fashion in

which the pyrrole ring A is first bound to the deaminase followed by rings B, C and finally D

(Figure 2.2.). The dipyrromethane cofactor, which arises from the autocatalytic coupling of two

molecules of PBG, is covalently linked to the enzyme. The cofactor functions as a primer to

which the four substrate molecules are sequentially attached but is not itself incorporated into

the product, hydroxymethylbilane.

The fourth enzyme, uroporphyrinogen III synthase, converts the highly unstable

hydroxymethylbilane to uroporphyrinogen III and in this reaction the linear tetrapyrrole

molecule is closed to form a ring. In the absence of uroporphyrinogen III synthase,

hydroxymethylbilane may non-enzymatically close to uroporphyrinogen I. In normal

circumstances, this isoform is present only in minute amounts.

The four carboxylic groups of the acetic acid chains in uroporphyrinogen are removed in the

reaction catalysed by cytosolic uroporphyrinogen decarboxylase. In the presence of oxygen

coproporphyrinogen oxidase catalyses the removal of the carboxyl group and the two

hydrogens from the propionic groups of the pyrrole rings and forms vinyl groups at these

positions resulting in protoporphyrinogen IX.


Figure 2.1. Enzymes and intermediate products in the heme biosynthesis pathway.Ac= -CH2COOH; Pr= -CH2CH2COOH; Vi= -CH=CH2

REVIEW OF THE LITERATURE 12

In the seventh step of heme biosynthesis, six hydrogen atoms are removed from

protoporphyrinogen IX to form protoporphyrin IX, a reaction catalysed by protoporphyrinogen

oxidase. The oxidation of protoporphyrinogen may also occur non-enzymatically.

Finally, iron (Fe2+) is incorporated into protoporphyrin IX by a mitochondrial ferrochelatase,

also known as heme synthase.

The heme biosynthesis is regulated in distinctive manners in erythroid and non-erythroid tissues

but ALA synthase is the rate-limiting enzyme of heme biosynthesis in all tissues (Kappas et al.

1995). Two different genes code for ALA synthase: the nonspecific ALA synthase is ubiquitous

whereas the erythroid ALA synthase is expressed only in erythroid tissues (Kappas et al. 1995).

Biosynthesis of heme in the liver and in other non-erythroid tissues is regulated by a feedback

mechanism in which the end product heme regulates the synthesis of non-specific isoform of

ALA synthase at the transcriptional and translational level (Moore et al. 1987). The activity of

nonspecific ALA synthase may be also induced by various chemicals, drugs, lead, and alcohol

and reduced by glucose. The erythroid-specific isozyme of ALA synthase is, in contrast to the

nonspecific ALA synthase, upregulated by increased heme concentration (Fujita et al. 1991).

The ALA synthase activity is also regulated by many other factors, for example by

erythropoietin and by the availability of iron (May et al. 1995).

More detailed information about heme biosynthesis is available in the literature (e.g. Moore et

al. 1987, Kappas et al. 1995).

2.2. The porphyrias

The porphyrias are a heterogeneous group of metabolic disorders. They have been divided into

two groups, erythropoietic and hepatic porphyrias (Moore et al. 1987) according to the tissue

where the excess porphyrins or their precursors are mainly synthesized. In general, the clinical

m a n i f e s t a t i o n s o f p o r p h y r i a s a r e e i t h e r s k i n p h o t o s e n s i t i v i t y d u e t o

REV

IEW O

F THE LITER

ATU

RE

13

Table 2.1. Classification of porphyrias*Classification Deficient enzyme Manifestations Inheritance

Erythropoietic

Congenital erythropoietic porphyria Uroporphyrinogen III synthase Photosensitivity Autosomal recessive

Erythropoietic protoporphyria Ferrochelatase Photosensitivity Autosomal dominant/recessive

Hepatic

ALA dehydratase deficiency porphyria ALA dehydratase Chronic neurologic symptoms Autosomal recessive

Acute intermittent porphyria Porphobilinogen deaminase Acute attacks Autosomal dominant

Hereditary coproporphyria Coproporphyrinogen oxidase Acute attacks and/orexcessive skin fragility

Autosomal dominant

Variegate porphyria Protoporphyrinogen oxidase Acute attacks and/orexcessive skin fragility

Autosomal dominant

Porphyria cutanea tarda Uroporphyrinogen decarboxylase Excessive skin fragility Autosomal dominant/ sporadic

Hepatoerythropoietic porphyria Uroporphyrinogen decarboxylase Photosensitivity Autosomal recessive* Modified from Kappas et al. 1995


photoreactivity of porphyrins, neurovisceral dysfunction (acute attacks), or both (Kappas et al.

1995). Most of the porphyrias are inherited dominantly in autosomes. ALA dehydratase

deficiency and congenital erythropoietic porphyria have, however, autosomal recessive

inheritance. Furthermore, a significant number of patients with porphyria cutanea tarda are

sporadic cases (de Verneuil et al. 1978). Hepatoerythropoietic porphyria is a rare homozygous

form of the familial type of porphyria cutanea tarda (Toback et al. 1987). A summary of

different porphyria types is given in Table 2.1.

2.3. Acute intermittent porphyria

2.3.1. History

The modern history of acute porphyrias, reviewed extensively elsewhere (Goldberg and

Rimington 1962, Dean 1963, Tschudy et al. 1975), begins at the end of the 19th century, when

an increasing number of patients with abdominal pain and neurological symptoms was

described. The typical attacks of acute porphyria were associated already in these early days

with drug treatment.

Most of the porphyrin nomenclature is based on Hans Fischer's, a Nobel laureate in 1930,

studies on the heme biosynthesis in the 1920's. In 1937 Jan Waldenström, who had previously

worked in Fischer's laboratory, described over one hundred patients with acute porphyria, most

of whom originated from a small village in Northern Sweden (Waldenström 1937). In this study

the Mendelian dominant mode of inheritance in AIP was demonstrated for the first time. Later,

he proposed that porphyrias could result from enzyme defects in the heme pathway and was

also the first to use the term 'acute intermittent porphyria' (Waldenström 1957). A screening test

for porphobilinogen was introduced in 1941 by Watson, who also was Fischer's co-worker

(Watson and Schwartz 1941). He also introduced hematin for treatment of acute porphyrias

(Watson et al. 1978). In the 1960's Granick discovered that ALA synthase, the first step in heme

biosynthesis, is induced by chemicals which cause acute porphyria (Granick 1963, Granick

1966). This observation led to the concept that overproduction of ALA may represent the

primary genetic defect in all acute porphyrias (Granick 1966), but this hypothesis was soon


found to be false because increased activity of this enzyme by itself could not account for the

distinct patterns of porphyrin precursors and porphyrin excretion. The biochemical background

of AIP was confirmed when it was demonstrated that the disease is due to a defect in PBGD

(Miyagi 1970, Meyer et al. 1972).

The characterization of the porphobilinogen deaminase gene (Raich et al. 1986, Grandchamp

et al. 1987, Chretien et al. 1988, Lee 1991a, Namba et al. 1991) initiated multiple investigations

of the molecular genetic background of AIP, and today several mutations responsible for AIP

have been identified (see chapter 2.5.2).

The first Finnish patient with acute porphyria was reported in 1928 (Langenskiöld 1928). The

first comprehensive study of the prevalence and clinical characteristics of acute porphyrias in

Finland was reported in 1976 by Pertti Mustajoki and Pentti Koskelo (Mustajoki and Koskelo

1976). The prognosis, precipitating factors and associated diseases in Finnish patients with

acute porphyrias have been investigated thoroughly by Raili Kauppinen and Pertti Mustajoki

(Kauppinen et al. 1992).

2.3.2. Prevalence

AIP is the most common type of acute porphyria in most countries (Kappas et al. 1995), only

in the Republic of South Africa is the prevalence of variegate porphyria higher than that of AIP.

The prevalence of AIP in Finland has been estimated to be 3:100000 (Mustajoki and Koskelo

1976). In other countries the reported prevalence figures are similar or slightly higher: 5-

10:100000 in the United States of America, in Western Australia 3:100000 (Tschudy et al.

1975). The highest prevalence of AIP has been described in northern Sweden where the

prevalence is 100:100000 and, furthermore, in two small municipalities the prevalence is as

high as 0.5-2%. However, the overall prevalence of AIP in Sweden is only 10:100000

(Andersson 1997). In a study of healthy Finnish blood donors the prevalence of low PBGD

activity was 1:500 (Mustajoki et al. 1992) and similar figures were obtained in a study which

consisted of healthy French blood donors (Nordmann et al. 1997). This implies that the

prevalence of AIP, though asymptomatic, may be much higher than previously estimated.


2.3.3. Clinical features

Approximately 10-20% of the affected individuals experience acute attacks during their

lifetime and 50% of patients have milder symptoms typical for AIP (Kauppinen and Mustajoki

1992). Half of the subjects with decreased PBGD activity remain, thus, asymptomatic

throughout their lifetimes. Acute attacks are extremely rare before puberty and the first acute

attack usually manifests at an age between 15 and 40 years (Mustajoki and Koskelo 1976).

Table 2.2. Symptoms and signs of an acute attack*Abdominal pain 90%Dark or red urine 89%Vomiting 61%Constipation 56%Extremity and/or back pain 53%Muscle weakness 53%Mental symptoms 46%Hypertension (diast. A100 mmHg) 42%Tachycardia 40%Fever 35%Sensory loss 19%Convulsions 14%Respiratory muscle paralysis 14%Diarrhea 9%*Total of 774 patients. Data combined from(Waldenström 1957, Goldberg 1959, Stein andTschudy 1970, Wetterberg 1974, Mustajoki andKoskelo 1976, Andersson 1997)

The symptoms during the acute attacks are mainly related to neurological dysfunctions. The

incidence of symptoms and physical signs are listed in Table 2.2. Abdominal pain is almost

invariably present and in severe cases it may mimic 'acute surgical abdomen'. Dark or red urine

is also frequently observed but the presence of other symptoms varies considerably which

sometimes causes difficulties in making the right diagnosis. Unless treated, the symptoms of an

acute attack may proceed to lethal respiratory paralysis. Nowadays, however, life-threatening

symptoms during acute attacks seldom occur because of increased knowledge of precipitating

factors and improved therapy (Kauppinen and Mustajoki 1992). The course of an acute attack

is variable and porphyric symptoms may last from a few days to several weeks (Kappas et al.

1995). Some patients may have symptoms almost continuously, but the majority of


symptomatic patients have a few well-delineated attacks with relatively asymptomatic

intervening remissions (Kappas et al. 1995).

The porphyric attacks are often precipitated by environmental or endogenous factors, such as

changes in hormonal state (menstrual cycle and pregnancy), several therapeutic drugs (e.g.

barbiturates and sulphonamides), alcohol, infections, stress, and inadequate caloric intake

(Kauppinen and Mustajoki 1992, Kappas et al. 1995, Andersson 1997). According to a Finnish

survey, at present the most common cause for an acute attack is the menstrual cycle in females

and excessive alcohol consumption in males (Kauppinen and Mustajoki 1992). Avoiding the

precipitating factors usually decreases the incidence of attacks. Women at fertile age may need

hormonal therapy which suppresses their endogenous sex hormone production.

Some diseases are more common in patients with acute porphyria than in the normal

population. The risk for hepatocellular carcinoma is increased 61 to 114-fold (Kauppinen and

Mustajoki 1992, Andersson et al. 1996, Linet et al. 1999) and is the cause of death in about

one-quarter of AIP patients (Andersson et al. 1996). Chronic hypertension has been suggested

to be more common in patients with manifest AIP than in those with latent AIP or in healthy

controls in Swedish material of one large AIP family (Andersson and Lithner 1994): 56% of the

patients with manifest AIP had hypertension. However, the prevalence of chronic hypertension

was much lower (~24%) in the Finnish material which consisted of both AIP and variegate

porphyria patients from 53 families and, furthermore, the occurrence of hypertension did not

correlate with clinical manifestations (Kauppinen and Mustajoki 1992). When Finnish AIP

patients were compared to the general Finnish population, the prevalence rates of hypertension

with medication were higher only in two age-specific subgroups (Kauppinen and Mustajoki

1992). Cardiovascular mortality was not higher among AIP patients (Kauppinen and Mustajoki

1992, Andersson et al. 1996). The prevalence of chronic renal failure has been suggested to be

higher among AIP patients (Kauppinen and Mustajoki 1992, Andersson and Lithner 1994).


2.3.4. Pathogenesis

Under normal conditions, the heme biosynthesis pathway is able to fulfill its task inspite of

decreased PBGD activity. It is widely presumed that increased metabolic demand for heme in

the liver leads to an induction of ALA synthase expression (Kappas et al. 1995, Elder et al.

1997). This results in accumulation of intermediates of the heme biosynthesis pathway, namely

delta-aminolevulinic acid and porphobilinogen, since the defective enzyme is not able to

convert all the porphobilinogen to hydroxymethylbilane. The resulting deficiency of the final

product, heme, leads to further induction of ALA synthase provoking circulus vitiosus, an

escalating metabolic chain reaction.

About 65 percent of the aminolevulinic acid produced in the rat liver is utilized for the

formation of CYP isoenzymes (Sassa and Kappas 1981). Some drugs, alcoholic beverages and

steroid hormones, i.e. substances which are known to precipitate porphyric symptoms, are

known to induce or increase the inducibility of hepatic ALA synthase and may also increase the

intrahepatic requirement for heme by inducing the synthesis of CYP isoenzymes (Elder et al.

1997). This leads to the accumulation of delta- aminolevulinic acid and porphobilinogen

because the deficient PBGD cannot fulfill the requirements of the accelerated heme

biosynthesis.

The symptoms of AIP result from neurologic dysfunction and acute attacks are known to be

caused by the induction of ALA synthase. However, the details of molecular pathogenesis are

still obscure. Three major hypothesis has been proposed to explain the symptomatology of an

acute attack (Moore et al. 1987, Kappas et al. 1995):

1) depletion of heme in the cells of the central nervous system (Lindberg et al. 1996, Lindberg

et al. 1999),

2) neurotoxicity of accumulated intermediates, especially aminolevulinic acid (Bonkovsky

1993), and

3) neurotransmitter disturbance secondary to the deficiency of heme and tryptophan pyrrolase

(a heme dependent enzyme) in the liver (Litman and Correia 1983).


Although all these theories are supported by some experimental findings, none of them can

explain all the various symptoms during an acute attack, and the pathogenetic mechanisms of

an acute attack remain, thus, unsolved.

The development of a transgenic porphobilinogen deaminase deficient mouse (Lindberg et al.

1996, Lindberg et al. 1999) is the first experimental model for acute porphyrias. Studies with

PBGD (-/-) mice suggest that heme deficiency and consequent dysfunction of hemeproteins

cause chronic and progressive neuropathy leading to impairment of motor coordination and

muscle weakness (Lindberg et al. 1999). However, the mouse model more resembles the

chronic neuropathy seen in some patients and it has not yet been able to elucidate the

pathogenetic mechanisms of acute attacks.

2.3.5. Biochemical findings

During an acute attack AIP patients always excrete increased amounts of the porphyrin

precursors, delta-aminolevulinic acid and porphobilinogen, in urine (Bissel 1982). Qualitative

tests, e.g. Watson-Schwartz and Hoesch tests (Bissel 1982), have been developed for rapid

confirmation of diagnosis, but sensitivity or specificity of these tests limit their usefulness

(Lamon et al. 1977). A quantitative assay (Mauzerall and Granick 1956) has been used for more

precise diagnosis. During the asymptomatic phase more than one half of AIP patients do not

excrete PBG in urine and these patients are less susceptible to acute attacks (Kauppinen and

Mustajoki 1992).

Biochemical diagnosis of acute intermittent porphyria is based on measurement of erythrocyte

porphobilinogen deaminase activity (Magnussen et al. 1974, Ford et al. 1980). In this assay,

porphobilinogen is used as a substrate and the uroporphyrin I formed is measured by

spectrofluorometry. In general, the erythrocyte PBGD activity in AIP patients is ~50% of that

found in normal subjects. Due to alternative splicing of the erythroid and wild type isoform

(Grandchamp et al. 1987), however, the erythrocyte PBGD activity is normal in the variant

form of AIP (Mustajoki 1981). Furthermore, there are wide individual variations of PBGD

activity among healthy controls (Mustajoki et al. 1992) and the normal and pathological values


have an overlapping zone. In addition, many diseases - for example renal insufficiency, iron

deficiency anemia and various malignancies - may affect PBGD activity (Moore et al. 1987).

These confounding factors limit the usefulness of biochemical methods in the diagnosis of AIP.

2.3.6. CRIM subtypes

Before the DNA era, AIP was divided into two major subtypes according to the ratio of enzyme

activity and the amount of immunoreactive protein in erythrocytes (Anderson et al. 1981,

Desnick et al. 1985, Lannfelt et al. 1989a). When the amount of immunoreactive protein

reflects the amount of enzymatically active protein, the patient is classified as cross-reactive

immunologic material (CRIM) negative. CRIM negative patients have been further divided into

two groups according to the PBGD activity in their erythrocytes: in type 1 the enzyme activity

is 50% of the normal activity whereas in type 2 the erythrocyte activity is normal. Several

explanations have been proposed for the absence of detectable mutant protein, i.e. CRIM

negativity (Mustajoki and Desnick 1985): instability of mutant mRNA, insufficient translation,

rapid intracellular decay of the mutant polypeptide, or due to an altered structure, the antibody

fails to detect the mutant polypeptide.

Enzymatically inactive but immunologically detectable protein is detected in erythrocytes of

CRIM positive patients. Two CRIM positive subtypes have been identified. In type 1 the ratio

of the protein and enzyme activity is ~1.6, i.e. the amount of inactive enzyme is 60-80% of that

of the active enzyme. In type 2 the CRIM/activity ratio is ~5.7, i.e. the amount of inactive

enzyme is 5.7-fold that of the active enzyme. In both CRIM positive subtypes the amount of

enzyme intermediates is increased (Anderson et al. 1981, Desnick et al. 1985), suggesting that

the enzyme protein is synthesized normally but it cannot catalyze deamination or elongate the

pyrrole chain normally.

2.4. Porphobilinogen deaminase

PBGD is a monomeric enzyme and in humans two isoforms are present: the 44 kD house-

keeping enzyme and the 42 kD erythroid-specific enzyme. The ubiquitous polypeptide, which


consists of 361 amino acid residues, is encoded by a single gene on chromosome 11q, and the

two isoforms differ only in their N-terminal amino acid sequences; the first 17 amino acids of

the wild type enzyme are not present in the erythroid isoform (Grandchamp et al. 1989c). Since,

the deaminases show exceptional heat stability, their characterization has been very convenient

(Shoolingin-Jordan 1995).

2.4.1. Function

PBGD catalyzes the tetramerization of porphobilinogen. The reaction produces a highly

unstable 1-hydroxymethylbilane (preuroporphyrinogen) intermediate which is followed by the

formation of cyclic tetramere uroporphyrinogen by uroporphyrinogen III synthase. PBGD

assembles the four rings of PBG in a step-wise fashion, in which the pyrrole ring A is first

bound to the deaminase followed by rings B, C, D (Figure 2.2.) The dipyrromethane cofactor

anchors the substrate molecules at the catalytic center and directs the construction of the

tetrapyrrole (Jordan and Warren 1987). The cofactor is formed by autocatalytic coupling of two

molecules of PBG, the same molecule which also acts as the substrate for the reaction.

Figure 2.2. Reaction cascade catalyzed by porphobilinogen deaminase


Figure 2.3. Schematic representation of human PBGD secondary structural elements. Basedon a crystal structure of E. coli enzyme (Louie et al. 1992) and on a model of human PBGD(Brownlie et al. 1994).

The enzyme-intermediate complexes have been isolated and studied further (Warren and Jordan

1988). Of these, the first intermediate complex (i.e. the enzyme with one substrate molecule

bound) is the most labile and the second intermediate the most stable at 37oC. The last enzyme-

intermediate complex, in which all four porphobilinogen rings are attached to the enzyme via

the dipyrromethane cofactor, does not accumulate at all, presumably due to rapid release of the

tetrapyrrole from the enzyme.

PBGD has, thus, the ability to perform multiple chemical reactions despite its small size. The

enzyme catalyzes the repetitive condensation of PBG units with an acceptor pyrrole chain and

is able to 'count' precisely and terminate the reaction when the tetrapyrrole chain has been

assembled. In addition, the apoenzyme installs its own dipyrromethane cofactor to form the

holoenzyme.


2.4.2. Structure

The structure of human PBGD has been predicted using the three-dimensional structure of

PBGD purified and crystallized from E. coli (Louie et al. 1992, Brownlie et al. 1994). The

molecule is composed of three domains of similar sizes linked together by flexible hinge

regions (Figure 2.3.). The enzyme possesses a single active site that is used for each

porphobilinogen condensation (Warren and Jordan 1988, Louie et al. 1992). In E. coli (the

corresponding human residues are in parenthesis), the dipyrromethane cofactor is covalently

bound to cysteine-242 (Cys261). In addition, residues aspartate-84 (Asp99), arginines 131, 132,

149, 155 (Arg149, 150, 167, 173), lysine-83 (Lys98), as well as some other residues form salt-

bridge and hydrogen bond interactions with the cofactor (Brownlie et al. 1994). The positively

charged side chains of Arg11, 132, and 155 (Arg26, 150, 173) are thought to interact with the

substrate (Lambert et al. 1994).

Fifty-eight residues in the PBGD polypeptide are invariant according to amino acid sequence

deduced from the nucleotide sequence determination from a wide range of organisms, and the

conserved amino acids are clustered in hydrophobic core of the molecule, in other

conformationally important locations, or at the active site. This suggests a similar structure and,

furthermore, similar mechanism of catalytic activity in organisms with different phylogenetic

age (Brownlie et al. 1994).

2.5. Molecular genetics of acute intermittent porphyria

2.5.1. The porphobilinogen deaminase gene

The gene coding for PBGD, which has been identified and thoroughly characterized (Raich et

al. 1986, Grandchamp et al. 1987, Chretien et al. 1988, Lee 1991a, Namba et al. 1991, Yoo et

al. 1993), is assigned to chromosome 11q24 (Namba et al. 1991). The size of the gene is 10 kb

of which 1.3 kb represents coding sequence. The genomic sequence is divided into 15 exons

ranging from 39 and 438 bp and 14 introns ranging from 87 to 2913 bp (Figure 2.4.).


Figure 2.4. The porphobilinogen deaminase gene and two mRNAs transcribed by alternativesplicing.

Two isoforms, arising from different promoters, are transcribed (Chretien et al. 1988). The

mRNA of the housekeeping (non-erythropoietic) isoform contains exons 1 and 3 to 15 coding

for an enzyme of 361 amino acids, whereas the erythroid isoform is encoded by exons 2 to 15

(Figure 2.4). The translation initiation codon for the housekeeping isoform is located in exon 1

and for the erythroid-specific isoform in exon 3. The erythroid isoform, thus, lacks the first 17

amino acids of the amino terminus.

The erythroid promoter region is located in intron 1 and its structure is very similar to that of

the β-globin gene (Chretien et al. 1988). The erythroid-specific transcript, thus, appears to be

regulated by similar set of transcription factors, suggesting that both genes are similarly

regulated during erythroid differentiation (Mignotte et al. 1989). The promoter region for the

housekeeping transcript is located upstream of exon 1 (Chretien et al. 1988, Yoo et al. 1993).

The minimal promoter sequence has been identified by deletion mapping (Lundin and Anvret

1997) and it is located between -243 and -115 nucleotides from the translation initiation codon.

This region contains two Sp1 consensus recognition sequences, a 13 bp repeat sequence, and an

AP1 consensus recognition sequence. In addition, sequence elements that have negative

regulatory function are located closer to the translational initiation site (Lundin and Anvret

1997).


To date, thirteen intragenic polymorphisms have been identified in the PBGD gene (Lee and

Anvret 1987, Llewellyn et al. 1987, Lee et al. 1988, Gu et al. 1991, Lee 1991b, Picat et al.

1991, Daimon et al. 1993a, Yoo et al. 1993, Law et al. 1999, Whatley et al. 1999). One of the

polymorphisms is exonic, located in exon 10, but it does not alter the amino acid sequence.

Nine polymorphisms are located in intron regions of the gene; four of them are found in intron

1, the longest (2.9 kb) intron in the PBGD gene. In addition to the intragenic polymorphisms,

two polymorphisms have been identified in the non-erythroid promoter region (Picat et al.

1991, Schreiber et al. 1992, Lundin and Anvret 1997).

Six Alu elements have been found in the intronic sequences of the PBGD gene. Alu elements

are derived from 7SL RNA by internal deletions or point mutations of the 7SL sequence

followed by dimerization (Makalowski et al. 1994). They integrate throughout the primate

genomes via a process called retroposition (Rogers 1985) which involves generation of an RNA

polymerase III transcript, reverse transcription, and integration at staggered nicks within AT-

rich regions of the genome (Jagadeeswaran et al. 1981). A typical Alu element is 282

nucleotides long and it is composed of two homologous but distinct subunits. Alu repeats can

be divided into various subfamilies based on the presence of commonly shared diagnostic

mutations (Jurka 1993). Two of the Alu sequences in the PBGD gene are located in the 5'

flanking region, three in intron 1. The sixth Alu element is in intron 9 and is the only Alu in

sense orientation. Five of the Alu sequences belong to the relatively modern Sa subfamily

whereas one is homologous to the older J subfamily (Yoo et al. 1993).

2.5.2. Mutations resulting in AIP

Up to July 1999, 149 different mutations resulting in AIP had been identified in the PBGD gene

worldwide (Table 2.3.).

Of the mutations, 56 (38%) are substitutions of one amino acid and 37 (25%) mutations affect

splicing. Fifteen mutations result in an immediate termination codon and, furthermore, 36

mutations cause frame shifts which have been predicted to lead to a premature termination

codon after a variable number missense amino acids. One mutation hits the translation initiation


Figure 2.5. Location and type of identified mutations in the PBGD gene

codon and the remaining three mutations are deletions or insertions, which do not cause frame

shift.

Figure 2.5. shows the distribution of the mutations by location and mutation type. No mutations

causing AIP have been identified in exon 2 and its flanking sequences. This was somewhat

expected, because exon 2, transcribed only to the erythroid mRNA, does not code for

polypeptide since the initiation codon of this isoform is located in exon 3. Mutations

responsible for AIP are dispersed quite evenly in the PBGD gene and there is no hot spot for

the mutations. Twenty-nine (19%) of the mutations are located in exon 12, which is clearly the

highest number of all exons, but this exon the second longest exon in the PBGD gene and it is

almost twice as long as the majority of other exons (Figure 2.4.). Notably, six of eight residues

known to be crucial for the enzyme activity (R26, K93, D94, R149, R150, R167, R173, and

C261) are substituted resulting in AIP, only at positions K93 and R150 there are no reports of

mutations so far.

In the light of the mutations published in the PBGD gene so far, the molecular genetic

background is highly heterogeneous despite the rather uniform clinical manifestations of the

disease. Although studies of geno/phenotype comparisons have not yet been published, nothing


implies that the type or the location of the mutation affects the clinical manifestations of the

disease. Furthermore, it seems that most of the mutations in the PBGD gene dramatically

decrease the enzymatic activity of the polypeptide encoded by the mutant allele.

REV

IEW O

F THE LITER

ATU

RE

28Table 2.3. Characterized mutations in the PBGD gene.Mutation Outcome Ref.* Mutation Outcome Ref.* Mutation Outcome Ref.*Exon 13G T translation defect (1)33G T splicing defect (2)Intron 1IVS1+1G A splicing defect (3)IVS1+2T A splicing defect (4)IVS1+5C G splicing defect (4)Exon 364C T R22C (5)66C G del exon 3 (6)70G A G24S (7)77G A R26H (8)83G A S28N (9)Intron 3IVS3+1G A splicing defect (10)Exon 491G A A31T (11)91G C A31P (12)100C A Q34K (13)125T A L42X (14)125T C L42S (12)158insA frame shift (7)Intron 4IVS4+1G A del exon 4 (12)IVS4+1G T del exon 4 (9)IVS4-6C G del exon 5 (12)IVS4-2A C del exon 5 (12)IVS4-1G C splicing defect (15)Exon 5163G T A55S (11)168delGT frame shift (16)174delC frame shift (11)181G A D61N (12)182insG frame shift (11)184delAA frame shift (12)206delCT S69X (9)

Intron 5IVS5+1G A del exon 5 (11)IVS5+2insG del exon 5 (9)IVS5+2T C del exon 5 (12)Exon 6218delAG frame shift (11)254T G L85R (12)Intron 6IVS6+1G C splicing defect (17)Exon 7269T G V90G (12)277G T V93F (1)287C T S96F (18)291delG frame shift (7)295G C D99H (18)314insC frame shift (16)323insT frame shift (12)331G A G111R (19)340insT frame shift (12)342C A C114X (9)Intron 7IVS7+33G T del exon 7 (12)IVS7-1G A del exon 8 (20)Exon 8346C T R116W (21)347G A R116Q (22)356C T P119L (10)365C G A122G (23)371T A V124D (9)del 704 bp frame shift (23)421delG del exon 8 (12)Intron 8IVS8+1G T splicing defect (10)Exon 9446G A R149Q (24)

446G T R149L (11)463C T Q155X (25)470insA frame shift (26)489insTCCT frame shift (12)Intron 9IVS9-1G A del exon 10 (27)Exon 10499C T R167W (28)500G A R167Q (29)500delG frame shift (9)517C T R173W (30)517del17bp frame shift (9)518G A R173Q (29)530T G L177R (13)532G A D178N (9)541C T Q181X (12)576del 19bp frame shift (9)589del 17bp frame shift (31)593G A W198X (32)601C T R201W (27)604delG frame shift (26)610C T Q204X (22)612G T del 3 aa (24)Intron 10IVS10+2TAGGG CCCTA

splicing defect (15)IVS10+2T C del exon 10 (9)IVS10-31A G del exon 11 (9)Exon 11625G A E209K (33)629delA frame shift (34)639T G Y213X (9)646G A G216D (17)650A T Q217L (35)651G T Q217H (9)

REV

IEW O

F THE LITER

ATU

RE

29

Mutation Outcome Ref.* Mutation Outcome Ref.* Mutation Outcome Ref.*Intron 11IVS11+1G C splicing defect (15)IVS11+2T C ins intron 11 (12)IVS11+3C G splicing defect (6)IVS11-2A G splicing defect (15)IVS11-1G C del exon 12 (9)IVS11-1delG del exon 12 (9)Exon 12656C A A219D (12)667G A E223K (11)678insAA frame shift (12)691del30bp truncated protein? (9)715delCA frame shift (14)716insC frame shift (31)721delC frame shift (12)723ins21bp 7 aa repeat (9)730delCT frame shift (36)734T G L245R (24)739T C C247R (36)742ins8bp frame shift (11)748G C E250A (10)748ins8bp frame shift (12)748G A E250K (11)749A T E250V (9)

749A C E250A (9)754G C A252T (37)754G A A252T (36)755C T A252V (36)761T C L254P (23)766C A H256N (13)766C T H256Y (9)771insT frame shift (38)771G A del exon 12 (39)771G C del exon 12 (40)Intron 12IVS12+1G A del exon 12 (14)IVS12+1G T del exon 12 (7)IVS12-1G A del exon 13 (9)Exon 13782G A C261Y (23)794insAGCC frame shift (12)799G A V267M (7)806C T T269I (22)809C A A270D (9)809C G A270G (31)820C A G274R (22)823C T Q275X (9)

Intron 13IVS13+1G A del exon 13 (6)Exon 14847delTG frame shift (17)848G A W283X (22)849G A W283X (16)854delTA frame shift (9)863C A S288X (9)863C G S288X (15)866delATAG frame shift (12)874C T Q292X (35)900insT frame shift (41)900delT frame shift (24)Intron 14IVS14+1G T del exon 14 (12)IVS14+1G A del exon 14 (19)Exon 15913insC frame shift (14)973C T R325X (42)982delG frame shift (12)986insT frame shift (15)1004delG frame shift (5)1004G A G335D (9)1062insC frame shift (43)

* 1, Chen et al. 1994; 2, Grandchamp et al. 1989c; 3, Grandchamp et al. 1989b, 4, Puy et al. 1998; 5, Ong et al. 1998; 6, Llewellyn et al. 1996; 7,Rosipal et al. 1997; 8, Llewellyn et al. 1993; 9, Puy et al. 1997b; 10, Lundin et al. 1995; 11, Gu et al. 1994; 12, Whatley et al. 1999; 13, Mgone et al.1992; 14, Puy et al. 1996; 15, Petersen et al. 1998; 16, Schreiber et al. 1995a; 17, Lundin et al. 1997; 18, Deybach and Puy 1995; 19, Gu et al. 1993a;20, Schreiber et al. 1994b; 21, Lee et al. 1990; 22, Mgone et al. 1994; 23, Brownlie et al. 1994; 24, Delfau et al. 1991; 25, Scobie et al. 1990; 26,Schreiber et al. 1994a; 27, Lundin et al. 1994; 28, Gu et al. 1992; 29, Delfau et al. 1990; 30, Lee 1991a; 31, Lee and Anvret 1991; 32, Puy et al.1997a; 33, Grandchamp et al. 1992; 34, Lee et al. 1994; 35, Schneider-Yin et al. 1999; 36, Mgone et al. 1993; 37, article IV; 38, Ong et al. 1996; 39,Grandchamp et al. 1989a; 40, Daimon et al. 1993b; 41, Schreiber et al. 1995b; 42, Petersen et al. 1996; 43, Daimon et al. 1994

AIMS OF THE STUDY 30

3. AIMS OF THE PRESENT STUDY

In the beginning of this study in 1993, the specific mutation resulting in AIP was identified only

in 9 (23%) of the 40 known Finnish AIP families. Furthermore, at that time very little was

known about the molecular mechanisms of how a mutation in the PBGD gene results in a

defective enzyme.

The aims of this study were:

1) To identify the gene defects resulting in AIP among Finnish patients.

2) To develop a method for screening of the PBGD gene for novel mutations and to develop

methods for DNA diagnostics of AIP for Finnish families.

3) To characterize the consequences of selected AIP mutations at the mRNA or polypeptide

and cellular level.

MATERIAL AND METHODS31

4. MATERIAL AND METHODS

4.1. Patients

A register for Finnish porphyria patients was established in 1966 and to date it comprises of

approximately 250 AIP patients belonging to 40 different families (Kauppinen and Mustajoki

1992). In the classical form of AIP the diagnosis has been based on typical clinical

manifestations or on increased excretion of porphobilinogen in urine (Mauzerall and Granick

1956) and on low PBGD activity in erythrocytes (Ford et al. 1980). In the majority of cases, the

pedigrees have been traced up to the 19th century and in some cases up to the 17th century

(Mustajoki and Koskelo 1976). According to this analysis, the families are not related to each

other. A DNA sample, and in most cases also a RNA sample, was available from at least one

patient from each family. In addition, DNA samples of healthy family members and healthy

unrelated controls have been available. The study protocol has been approved by the Ethics

Committee of the Third Department of Medicine, University of Helsinki.

4.2. DNA and RNA isolation, and cDNA synthesis

Leukocyte DNA was extracted from venous blood samples using the method described in

(Sambrook et al. 1989) or DNA was released from leukocytes as described by Higuchi (1989).

Total RNA was prepared from lymphoblastoid cells using the guanidium isothiocyanate method

(Chirgwin et al. 1979). Complementary DNA was synthesized from 2-5 µg of total RNA using

M-MuLV Reverse Transcriptase (New England Biolabs, ME, USA), RNase inhibitor (RNAsinR

Promega, WI, USA), dNTPs, and random hexanucleotide mix (Boehringer Mannheim,

Germany) or a specific primer for 3' untranslated region of the PBGD gene.

4.3. DNA amplification

Isolated DNA (final concentration 2-5 ng/µl), lysed leucocyte sample (1:10 v/v), or RT product

(3:20 v/v) was used as the template for polymerase chain reaction (PCR, Mullis and Faloona

1987). The PCR reaction mixture contained 16-23-mer primers (0.2-1 mM), dNTPs at 0.2 mM

MATERIAL AND METHODS 32

concentrations and 0.03 U/µl of DNA polymerase (DynazymeR, Finnzymes, Finland) in enzyme

buffer. The temperature profile for the PCR reactions was 2 min at 94oC for the first

denaturation step, followed by 30-60 s at 94oC, 30-60 s at 54-60oC, and 30-90 s at 72oC for 30

cycles. The other primer was biotinylated if the PCR product was used in sequencing or

minisequencing reactions. The primer sequences are given in original articles I-V.

4.4. Subcloning

When the consequences of mutations in the exon/intron boundaries (IVS1+3G T and IVS13-

2A G) were studied, the normal allele interfered with direct sequencing and both alleles were

studied separately by subcloning. In the case of Alu insertion, the normal allele and poly T

region interfered with direct sequencing of the branch points, and the 318 bp and 651 bp

fragments including exon 5 were amplified from a patient's genomic DNA sample. After

amplification, digestion and purification, the fragments were ligated into the corresponding

restriction sites of the pUC18 vector (Pharmacia, Sweden), transformed in E. coli and both

alleles were sequenced separately.

4.5. Mutation screening

Mutations were examined using two different screening methods: single-strand conformation

polymorphism (SSCP, Orita et al. 1989) and denaturing gradient gel electrophoresis (DGGE,

Myers et al. 1987, Nissen et al. 1995). Prior to SSCP, the 32P-labeled PCR products, which

covered exon 1 and exons 3 to 15 of the PBGD gene, were digested into shorter fragments

when longer than 500 bp. The primer sequences and restriction enzymes used are given in

article I. The samples were diluted 1:5 in 1% sodium dodecyl sulfate (SDS)/10mM edetate

disodium tetraacetic acid (EDTA), mixed with an equal volume (3 µl) of 95% (vol/vol)

formamide/20 mM EDTA containing 0.05% bromophenol blue and 0.05% xylene cyanol, and

denatured by heating. The diluted and denatured sample was electrophoresed in a 5%

bis/acrylamide (60:1) gel using different glycerol and TBE-buffer concentrations at 4oC or

room temperature. After drying the gels were autoradiographied at -70oC for 12-48 h.


For DGGE, to the 5' end of one of the PCR primers was attached a 40-50-bp-long stretch of

guanosine and cytidine nucleotides (GC-clamp) to increase the sensitivity of DGGE (Sheffield

et al. 1989). The GC-clamped PCR-products were run on linearly increasing denaturing

gradient polyacrylamide gels of 20%-60% denaturant at 60oC for 5 hours. After electrophoresis,

the gel was stained with ethidium bromide and visualized with ultraviolet translumination.

4.6. Sequencing

The PCR products were purified using the Qiagen Gel Purification Kit (Qiagen, CA, USA) or

Fluoricon avidin-polystyrene-assay particles (Idexx Laboratories, ME, USA), which was used

if PCR was performed with biotinylated primers. The DNA was sequenced in both sense and

antisense directions using the dideoxynucleotide chain termination method (Sanger et al. 1977)

with commercial kits (Sequenase 2.0 Sequencing Kit, USB, OH, USA or Amplicycle

Sequencing Kit, Perkin Elmer, CT, USA) according to the manufacturers' instructions.

4.7. Solid-phase minisequencing

The solid-phase minisequencing method (Syvänen et al. 1993) was used to identify the variable

nucleotide in the sample. Figure 1 in article V shows schematically the steps of solid-phase

minisequencing. The method is suitable for screening a previously identified mutation, and it

may also be used for quantitative measuring.

PCR was performed as described above with the exception that the PCR mixture contained

biotinylated and unbiotinylated primers in proportion of 1:5. For each minisequencing reaction

10 µl of the PCR product and 40 µl of sodium phosphate buffer were added to streptavidin-

coated microtiter wells and incubated at 37oC for 90 minutes. The wells were washed three

times and denatured twice with sodium hydroxide at room temperature. To each well was added

50 µl mixture containing specific primer, DNA polymerase, and [3H]dNTP. The labeled

nucleotide was hybridized next to the minisequencing primer during the 10-minute incubation

at 50oC. The nucleotides not incorporated were washed out as described above. The primer


hybridized with labeled nucleotide was denatured with sodium hydroxide. The radioactivity

eluted with sodium hydroxide was counted in a liquid scintillation counter.

4.8. In vitro mutagenesis

Mutagenesis was performed using a Chameleon Double-Stranded Site-Directed Mutagenesis

Kit (Stratagene, CA, USA) according to the manufacturer's instructions. The full-length coding

region of the PBGD cDNA (Grandchamp et al. 1989a), used as a template, was ligated in

between the HindIII and EcoRI sites of mammalian expression vector SVpoly (Stacey and

Schnieke 1990). The oligonucleotides used in each mutagenesis reaction are given in

publication VI. The selection primer was located in the polylinker region of SVpoly which

removed the cleavage site for XbaI. Mutant clones were confirmed by sequencing.

4.9. COS-1 cell culture and DNA transfection

COS-1 cells were maintained in Dulbecco's modified Eagle's medium (Gibco-BRL, NY, USA)

supplemented with 10% fetal heat-inactivated bovine serum and antibiotics. For transfection,

the cells were seeded on a 3 cm 6-well plate at 4*105 cells/well and grown overnight. The cells

were transfected with 1.5 µg of the plasmid construct by lipofection (Felgner et al. 1987) using

FuGENE 6 transfection reagent (Boehringer Mannheim, Germany). Forty-eight hours post-

transfection the cells were either harvested for the PBGD activity and Western blot analyses, or

pulse-chase experiments were performed.

4.10. Enzyme activity assay

One hundred µl of the cell lysate in 1.0 ml of 1% Triton X-100 was pre-incubated at +37oC for

15 minutes prior to adding 500 µl of 1.4 mM porphobilinogen in phosphate-citrate buffer (Ford

et al. 1980). The mixture was incubated for 30 minutes at +37oC and the reaction was stopped

with 2.5 ml of 10% trichloride-acetatic acid. The fluorescence of the supernatant was measured

using 100 µg/l uroporphyrin I standard at the excitation wavelength of 407 nm and the emission

wavelength of 598 nm. Protein concentration in a cell lysate was determined by a dye-binding


reaction (Bio-Rad Protein Assay, CA USA). An expression vector control was used to monitor

the background expression of PBGD in COS-1 cells.

4.11. Western blot

A mixture of 20 µl of cell lysate in phosphate-buffered saline (PBS) containing 1% Triton X-

100, 5 µl of 5 x Laemmli’s reagent (Laemmli 1970), 1 µl dithiothreitol , and 1 µl of 20% SDS

was run a 14% SDS-polyacrylamide gel. The gel was electroblotted on a nitrocellulose filter.

The filter was filled with 5 % bovine milk proteins and reacted with a 1:2000 dilution of

polyclonal rabbit anti-human-PBGD antibody (Lannfelt et al. 1989b). Anti-rabbit IgG-Alkaline

Phosphatase conjugate (1:7500, Promega) was used as a secondary antibody and the proteins

were visualized using 0.66% nitro blue tetrazolium and 0.33% 5-bromo-4-chloro-3-indolyl-1-

phosphate (Promega).

4.12. Pulse-chase and immunoprecipitation

The cells were starved in a cysteine- and methionine-free medium for 60 min before labeling

with 200 µCi/ml Promix (35S-Cys + 35S-Met, Amersham, UK). A one-hour pulse was followed

by 1-23 hour chase in normal medium without bovine serum. After the chase period the cells

were harvested and resuspended in PBS containing 1% Triton X-100 and lysed by freeze-

thawing three times.

The PBGD proteins were immunoprecipitated from the cell lysates using polyclonal rabbit

PBGD antibodies (1:2000) and formalin-fixed Staphylococcus aureus cells (Pansorbin cells,

Calbiochem, CA, USA, Proia et al. 1984). The labeled and precipitated proteins were separated

by 14% SDS-polyacrylamide gel and visualized by autoradiography.

4.13. Immunofluorescence

For immunofluorescence staining the transfected COS-1 cells were grown on 12 mm coverslips

and fixed in 3% paraformaldehyde for 30 min at room temperature. After fixation the cells were


washed in PBS and permeabilized in PBS containing 0.2% saponin, 0.5% bovine serum

albumin (BSA) for 30 min at room temperature. This was followed by incubation with a 1:2000

dilution of PBGD antibody for 30 min at room temperature. The cells were washed in PBS

containing 0.2% saponin and 0.5% BSA and incubated with 1:150 dilution of rhodamine-

conjugated secondary antibody against rabbit immunoglobulins (Immunotech, MA, USA) in the

same buffer for 45 min at room temperature. The cells were washed in PBS and mounted on

slides in 87% glycerol.

RESULTS AND DISCUSSION37

5. RESULTS AND DISCUSSION

Prior to this study 4 mutations in 9 Finnish AIP families had been identified (Kauppinen

1992a). The search for an underlying genetic defect in the remaining 31 families was begun

using SSCP analysis. The PCR fragments were designed to cover exons 1 and 3 to 15 of the

PBGD gene. Exon 2 was not analyzed, since it encodes only erythroid isoform. If a mobility

shift was detected in SSCP analysis, the corresponding PCR product was direct sequenced. The

identified mutations and their outcome are discussed in Chapters 5.1. and 5.5.

The sensitivity and specificity of the DGGE method for identifying mutations in the PBGD

gene was tested. Because two different screening methods - SSCP and DGGE - were used in

this series of investigation, their efficiency has been compared. However direct comparison was

not possible since the DGGE method was tested blindly and prospectively and the overall

sensitivity of SSCP method was analyzed retrospectively (Chapter 5.2.).

The steady state transcript levels of six different mutant alleles were accurately determined

using solid-phase minisequencing. In addition, whenever RNA isolated from the patient's

lymphoblastoid cell line was available, amplified cDNA was sequenced, which provides a

rough estimate of the transcript level of the mutant allele (Chapter 5.3.).

To study further the consequences of mutations in the PBGD gene, seven different mutant

cDNA constructs were produced and expressed in eukaryotic COS cells. The properties of

mutant proteins were investigated by PBGD activity measurements, and pulse-chase and

immunofluorescence studies (Chapter 5.4.).

5.1. Identified mutations (I, II, III)

The series of investigations presented here have revealed 22 additional defects in the PBGD

gene resulting in AIP (Table 5.1., Figure 5.1.). Combined with previously identified genetic

defects the 26 characterized mutations cover 38 (95%) of a total of 40 unrelated Finnish AIP

families.

RESULTS AND DISCUSSION 38

The mutation was always confirmed by direct sequencing the sample in the other direction or

by restriction enzyme analysis when available. When a mutation was identified and its

segregation with the disease was confirmed in the family, no further sequencing was performed.

In each patient, thus, one to 14 exons were sequenced before a mutation was identified. To

exclude a rare polymorphism, the nucleotide sequence of exons 12 and 14 in 50 Finnish

unrelated healthy controls was determined and this analysis revealed no sequence variations.

When performing the DGGE analysis of the patients’ genomic DNA samples, all mutations,

except the large insertion in exon 5, resulted in a deviated pattern in the corresponding exon.

None of the DGGE patterns similar to these mutations were observed when the DNA samples

of more than 50 Danish AIP patients were analyzed. In addition, a variable number of unrelated

healthy controls and healthy family members were analyzed for each mutation. Thus, a rare

polymorphism was considered very unlikely.

As in most other populations (Table 2.3.), also in Finland the AIP mutations are highly

heterogeneous both in their type and location. Furthermore, almost all mutations are family

specific. Thirteen (50%) mutations are located in exons 10, 12, and 14. Of the twelve missense

mutations (46% of all identified mutations), six are substitutions of an arginine residue. A

substitution of one base pair causes a nonsense codon in five cases. In addition, two deletions

and two insertions result in a frame shift leading to a premature termination codon after a

variable number of missense codons. Four mutations affect the splicing of the primary

transcript. As a consequence of two splicing mutations (IVS+3G T, IVS13-2A G), the intron

sequence is retented into the transcript and a premature termination codon is introduced. One

splicing mutation (86A T) was shown to result in exon skipping and a truncated protein, but

in the case of a splicing defect in exon 1 (33G T) no mutant transcript could be detected

(Kauppinen 1992b). Deletion of one nucleotide in the last exon results in a frame shift which

removes the normally utilized termination codon and no additional termination codon is

available before the polyadenylation signal.

In two (5% of all Finnish AIP families ) AIP patients the genetic defect causing AIP remains

unknown. In these patients, the diagnosis was based on typical clinical manifestations and on

increased excretion of porphobilinogen in urine and/or on low PBGD activity in erythrocytes.


Figure 5.1. Identifying the mutation bydirect sequencing. As an examplemutation 673C G.

Both patients are the only affected individuals in their families. In the one patient's sample there

was a mobility shift in exon 11 when DGGE analysis was performed, whereas the other

patient's DGGE analysis was negative. The entire coding sequence and flanking intronic

regions were sequenced and no nucleotide alteration was found in the genomic DNA samples

of these patients. Neither did the amplification of the PBGD gene in long fragments (3.4-4.5

kb) reveal additional information.

The genetic defect remained unsolved in some cases also in a French study, where the

mutations were systematically searched for using DGGE analysis and sequencing (Puy et al.

1997b). The patient material comprised of 405 patients from 121 unrelated AIP families, and in

1 2 ( 1 0 % ) f ami l i e s t he DGGE sc reen in g w a s n o r ma l a n d n o b a s e c h a n ge s

were identified despite sequencing all exons and exon/intron junctions. Based on the data from

Finland and France, sequencing only the coding areas and flanking intronic regions of the

PBGD gene does not seem to guarantee the detection of all mutations. In these patients the

underlying defect may be the in promoter region, in the middle of intronic sequence, or it may

be a large insertion or deletion which remains non-detectable with the methods used in these

s tud ie s . Because the en zyme a c t i v i t y me a s u r e me n t h as wide ove r l app ing

zone and urinary PBG and dALA are elevated also in other porphyrias, the subjects may also

have been misdiagnosed as AIP patients.


Table 5.1. Identified mutations in Finnish AIP patients

Mutation Location Outcome cDNAa CRIMb Enzymec No. offamilies Ref.d

1 33G T 1 splicing defect - - HphI 1 (1)

2 IVS1+3G T intron 1 intron 1 retention + - HphI 1 II

3 76C T 3 Arg26 Cys + + BspMI 1 I

4 86A T 3 exon 3 skipping + - BstXI 1 II

5 97delA 4 frame shift + - 3 I

6 100C T 4 Gln34 Stop + - 1 I

7 Ins 332 bp 5 frame shift - - 1 III

8 293A G 7 Lys98 Arg n.d. - NlaIV 1 I

9 346C T 8 Arg116 Trp - - 1 (2)

10 417insCA 8 frame shift n.d. - 1 II

11 445C T 9 Arg149 Stop - - 2 I

12 499C T 10 Arg167 Trp + + 5 (3)

13 517C T 10 Arg173 Trp + -/(+) MspI 2 (4)

14 518G A 10 Arg173 Gln + + MspI 4 (5)

15 583C T 10 Arg195 Cys n.d. - HhaI 1 I

16 593G A 10 Trp198 Stop - - NheI 1 (6)

17 664G A 12 Val222 Met + - 1 II

18 673C G 12 Arg225 Gly + - NlaIV 1 I

19 673C T 12 Arg225 Stop - - 2 I

20 713T G 12 Leu238 Arg - - BbvI 1 I

21 740G T 12 Cys247 Phe + - Fnu4HI 1 I

22 IVS13-2A G intron 13 intron 13 retention + - MspI 1 II

23 833T C 14 Leu278 Pro + - BslI 1 II

24 838G A 14 Gly280 Arg - - MaeI 1 I

25 886C T 14 Gln296 Stop - - 1 I

26 1073delA 15 frame shift - - MseI 1 Ia +, mutation seen in cDNA; - mutation not seen in cDNA; n.d., not done.b CRIM, cross-reactive immunologic material; +, inactive protein detected;

-, no inactive protein detected.c Mutation specific restriction enzyme.d First described by: 1, Grandchamp et al. 1989b; 2, Lee et al. 1990; 3, Gu et al. 1992;

4, Lee 1991a; 5, Delfau et al. 1990; 6, Lee and Anvret 1991.


5.2. SSCP and DGGE in screening for novel mutations (I, II, III, IV)

Mutations were searched for using two different screening methods: single-strand conformation

polymorphism (SSCP, Orita et al. 1989) and denaturing gradient gel electrophoresis (DGGE,

Myers et al. 1987, Nissen et al. 1995). SSCP analysis is based on the mobility shifts of a single-

stranded DNA under renaturing conditions. During electrophoresis the single-stranded DNA

rehybridizes and the migration position is determined by the secondary structure, which is

influenced by the sequence variants. In DGGE analysis the amplified DNA samples are run on

a gel, in which the amount of denaturant is gradually increased. Sequence variation in the

sample has an effect on the melting point which alters the migration. Previously, both SSCP

(Kauppinen et al. 1992, Chen et al. 1994, Schreiber et al. 1994a, Schreiber et al. 1994b,

Schreiber et al. 1994c, Schreiber et al. 1995b) and DGGE (Gu et al. 1992, Gu et al. 1993b, Gu

et al. 1994, Petersen et al. 1996, Puy et al. 1996, Nordmann et al. 1997, Puy et al. 1997a, Puy

et al. 1997b, Rosipal et al. 1997, Petersen et al. 1998, Puy et al. 1998) have been used in

searching for mutations responsible for AIP.

The overall sensitivity of SSCP in screening mutations of the PBGD gene was 90%, i.e.18 of

the 20 identified mutations could be detected using this method when five different

electrophoretic conditions (glycerol concentration was 0%, 5%, or 10% and the gel was run at

+4oC or at room temperature) were used. However, the sensitivity of SSCP was significantly

lower if only a single electrophoretic condition was used: gel electrophoresis at room

temperature with 5% and 10% glycerol detected 12/20 (60%) and 14/19 (74%) of the

mutations, respectively, while gel electrophoresis at +4oC without glycerol detected 15/19

(79%) of the mutations. The length of the analyzed PCR fragment had a variable effect on the

sensitivity of the analysis: in the case of mutation 97delA both an increase and a decrease in the

size of the fragment (510 bpÏ446 bp 324 bp or 189 bp) from the original resulted in a shift

and in SSCP analysis of mutation 1073delA even minor changes in the size of the fragment

(192 bp or 197 bpÏ211 bp 228 bp) caused disappearance of the mobility shift. The specificity

of the SSCP method was not evaluated in this study.


The efficacy of the DGGE method in detecting mutations causing AIP was evaluated by

analyzing blindly the DNA samples of 22 AIP patients and 6 healthy controls. As a result, the

correct mutation carrying region was found in samples of all 22 patients, but in two samples

two potential regions were initially highlighted. In both cases, the false positive pattern was

located in exon 7 and flanking intron sequencing, and sequence analysis revealed a previously

unknown polymorphism in intron 6. Common polymorphisms in the PBGD gene could easily

be distinguished from mutations because the number of analyzed samples was relatively high

and the location of polymorphic sequence variations was known. The DGGE patterns in all

healthy controls were normal, only common polymorphisms could be identified. In addition six

mutations described in article II, which were not included in the study with a blinded design,

resulted in a mobility shift in the corresponding region.

However, DGGE analysis could not identify the 333 bp Alu insertion located in exon 5. This

was expected since the length of the normal fragment covering exons 5 and 6 in DGGE analysis

is 393 bp and in the patient sample the PCR product is almost twice as long, 726 bp. The allele

with the insertion migrates more slowly and most probably will not reach the analytical area in

the gel by the end of the electrophoresis. When the results of these studies are combined, the

sensitivity of DGGE analysis was 96% (25/26 mutations could be identified with the method)

and the specificity was 94% (two false positive mobility shifts in 35 samples).

The DGGE and SSCP methods have previously been evaluated both in the screening of the

PBGD gene and several other genes, and the earlier results are in good agreement with the data

obtained from our experiments. When several sets of electrophoretic conditions is used, SSCP

detects 70-95% of mutations but using only one condition reduces the sensitivity considerably

(Michaud et al. 1992, Grompe 1993, Moyret et al. 1994). Furthermore, the sensitivity of this

method has been reported to be highest when the fragment size is below 200 bp (Grompe

1993), which limits the usefulness of the method when large genes are screened for mutations.

The sensitivity of DGGE has been estimated to be as high as 95-100% in several studies

(Grompe 1993, Moyret et al. 1994, Macek et al. 1997, Puy et al. 1997a, Puy et al. 1997b) and

single base differences can be detected with high accuracy in PCR products of up to 600 bp in

length.


DGGE appears, thus, to be superior in sensitivity when compared with SSCP. However, the

setup of the DGGE method is laborious: the running conditions of each fragment needs to be

optimized separately but tuning up of the system may be assisted by computer analysis. Once

conditions are finalized, the DGGE analysis proceeds rapidly. SSCP method has gained

popularity because of its simple and straightforward implementation. Although it is a powerful

method, the sensitivity of SSCP has not reached the same level as DGGE. Furthermore, the

method lacks guidelines for its optimization for a defined DNA sequence (Michaud et al. 1992,

Moyret et al. 1994) and it usually requires the use of radioactive nucleotides to label the

fragments to be analyzed.

5.3. Monitoring the effect of mutations to allelic transcript levels (V)

The steady state level of allelic transcripts in lymphoblasts of eight AIP patients were analyzed

using solid-phase minisequencing. The patients had the following mutations: 517C T

(R173W), 518G A (R173Q), 673C G (R225G), 673C T (R225X), 713T G (L278P) and

1073delA (frame shift). All mutations, except the missense mutation 517C T in exon 10,

affected the steady state transcript levels of the mutant allele (Table 5.2.). The mutant mRNA

levels in lymphocytes varied from 5 to 95% of the corresponding wild type allele levels. In

contrast to the CRIM negative mutation 517C T, the CRIM positive mutation in the same

codon 518G A resulted in reduction of the steady state transcript level of the mutant allele to

65% of that of the normal allele. Interestingly, the mutant transcript of the patient with mutation

517C T seemed to be more unstable than the normal transcript, because mutant transcript

seemed to degrade more rapidly during storage at -80oC. However, this preliminary finding was

not studied further.

Two of the mutations, 673C G or T (R225G or X), affecting the same nucleotide in exon 12

differed considerably in their effect on allelic transcript: the transcript level of the allele with

a missense mutation was decreased to 80% of that of the normal allele whereas the nonsense

mutation at the same position resulted in a dramatic decrease (5-fold) in the levels of the mutant

transcript. The mRNA samples of three subjects with the same nonsense mutation 673G T

(R225X) were also analyzed. Although clinical manifestations have been different in these


patients, the steady state transcript levels were almost identical: 23%, 20%, and 24% of the

normal allele.

Even though the data showed variations between the levels of mutant transcript in AIP patients,

the mutant transcript level did not correlate to the CRIM class, to the location of the disease

causing mutation in the PBGD gene, or to the clinical phenotype of AIP.

Nonsense codons have been reported to dramatically decrease the mRNA levels of the mutant

allele and, typically, the closer the mutation is to 5' end of the transcript, the more dramatic is

the effect (Cooper 1993). Direct sequencing of amplified cDNA product gives in most cases a

rough estimation of the steady state transcript level of the mutant allele, since the mutant allele

is detected if its level is at least 30% of the normal allele. In our material the mutant allele

could be detected in sequenced cDNA in the case of four nonsense mutations: IVS1+3G T,

97delA, 100C T, and IVS13-2A G (Table 5.1.). Total RNA from the patient with mutation

417insCA was not available, and the remaining five nonsense mutations were not detected

when the corresponding cDNA was sequenced. This suggests that mutant allele gets transcribed

at least to some extent in the case of four nonsense mutations. Three of these four mutations are

located in exons 1 or 3 and one in intron 13. Those mutations which could not be detected by

sequencing of cDNA are located in exons 1, 5, 8, 10, 12 and 14 (Table 5.1.). Thus, our results

are not in agreement with the data obtained from mutations of other genes, since in those

mutant alleles that are transcribed the mutations are located closer to the 5' end of the PBGD

gene than those mutant alleles that are not transcribed. However, the low number of mutations

and the lack of accuracy of this method prevents us from drawing any definitive conclusions

concerning this finding.

Mutations resulting in premature termination codons do not decrease the rate of gene

transcription (Urlaub et al. 1989, Cheng and Maquat 1993). However, in the majority of cases

the levels of mutant mRNA, imposed by premature termination codon, are decreased (Cooper

1993, Peltz et al. 1994, Maquat 1995). Previously, it was anticipated that mRNA decay would

take place in the cytoplasm, because termination codon recognition requires cytoplasmic

ribosomes. Several pieces of evidence have, however, implied that the low levels of mutant


transcripts are due to nuclear events (Urlaub et al. 1989, Baserga and Benz 1992, Cheng and

Maquat 1993, Cooper 1993, Simpson and Stolzfus 1994, Carter et al. 1996)

The mechanisms of how premature termination codons reduce mutant mRNA levels are

obscure. Carter and co-workers (Carter et al. 1996) demonstrated that at least two signals are

required to trigger the down-regulation of mutant mRNA: a nonsense codon and a spliceable

downstream intron. According to this result, thus, premature termination codons in the last

exon would not affect the mutant RNA level.

The translational-translocation model (Urlaub et al. 1989) proposes that during mRNA export

from the nucleus to the cytoplasm, the 5' end of a transcript is scanned by cytoplasmic

translational machinery while the 3' end is still undergoing mRNA splicing, which is a nuclear

event. The premature nonsense codon in the nuclear pore-associated mRNA, scanned by a

cytoplasmic ribosome, would ultimately result in the decay of the mRNA. The length of the

nuclear pore has been estimated to be 15 nm or ~45 nucleotides of linear mRNA (Alberts et al.

1994). According to this model, hence, a nonsense codon should be at least 60 nucleotides (an

additional 15 nucleotides are required for the termination codon to be positioned at the P site of

the ribosome) from a downstream intron to be recognized in the cytoplasm before the intron is

spliced out in the nucleus. The studies on the T-cell receptor β-gene, however, suggested that

the border for nonsense-mediated mRNA down-regulation is below 10 nucleotides from the

exon/intron junction (Carter et al. 1996), and these data are inconsistent with the translational-

translocation model.

In the marker model (Carter et al. 1996) a downstream intron could act as a second signal to

trigger down-regulation. This model is based on the presumption that after splicing the previous

location of intron is marked on mature mRNA. The potential marker is a specific SR protein,

which remains bound to exons after RNA splicing, or the marker may be RNA which has

undergone post-transcriptional modification. This model allows the triggering of mRNA decay

before it has completely exited the nucleus, even if the premature termination was scanned by

a cytoplasmic termination codon.


So far, the only known cellular structure that can scan codons is a cytoplasmic ribosome.

However, a model in which a nuclear component would recognize nonsense codon has been

proposed (Urlaub et al. 1989, Carter et al. 1996). Although there is no direct evidence for a

nuclear scanner, the model accounts for all the important features characterized in experiments:

mutant mRNA is destroyed in the nucleus, a spliceable intron acts as a second signal to trigger

mRNA down-regulation, and a nonsense codon may be located only 10 nucleotides upstream

of the last intron to trigger mRNA decay.

Unlike nonsense mutations, the effect of missense mutations on transcript levels has

characteristically been reported to be non-significant (Mustafa et al. 1995, Karttunen et al.

1996, Ploos van Amstel et al. 1996). In contrast, our results demonstrate that also missense

mutations can reduce the abundance of mutant mRNA. In our experiment we have used

Ebstein-Barr -virus infected lymphoblasts and the transcript levels in immortalized

lymphoblasts may differ from those in cells in vivo. However, an allele specific effect would be

unlikely and consequently we have here emphasized the relative ratios of mutant and wild type

allelic transcripts.

Table 5.2. Consequences of selected mutations on the steady-state transcript level andenzyme activity after eukaryotic expression.

Mutation Outcome CRIMMutant mRNA

as a ratio ofwild type mRNA

Enzyme activity±S.E. nmol/mg

prot/h b

76C T R26C + 105±17 (0%)

Alu insertion Trunc. protein - [270±80 (0%)]c

499C T R167W + 273±66 (5%)

517C T R173W - 0.97 173±33 (2%)

518G A R173Q + 0.66 140±11 (0%)

673C G R225G - 0.82 626±78 (16%)

673C T R225X - 0.22 142±9 (0%)

713T G L278P - <0.05

1073delA a frame shift - 0.72 1660±174 (50%)

Wild type 3173±507 (100%)


Control COS 127±7a Normally utilized termination codon abolished. The polypeptide synthesized by the

mutant construct differs from the predicted polypeptide in patients with thismutation.

b Mean value of four independent measurements. Percentage of mean normal activitycorrected with the endogenous COS-1 cell PBGD activity in parenthesis.

c Enzyme activity is not comparable because of separate assay.

5.4. Expression of mutated polypeptides (III, VI)

To analyze further the consequences of mutations on the function of PBGD enzyme, eight

mutations were introduced to PBGD cDNA and the mutated constructs were expressed in

eukaryotic COS cells. Six of the tested mutations (R26C, Alu insertion, R167W, R173W,

R173Q, R225X) resulted in the reduction of PBGD activity to the background level (0-5%).

These results confirm the assumed causality of the amino acid substitution and the low PBGD

activity measured in the patients’ erythrocytes. In two cases (R225G, 1073delA), however, the

enzyme activity was only partially disturbed and 16-50% residual activity could be detected

(Table 5.2.).

Western blot analysis shows that the mutant constructs R26C, R167W, R173W, R173Q, and

R225G expressed polypeptides which reacted with the antibodies directed against human

PBGD and the migration pattern was comparable with that of the normal enzyme (Figure 5.2.).

As predicted, the construct with mutation 1073delA removing the normally used termination

codon, produced a longer polypeptide. The constructs with R225X and Alu insertion, both of

which are predicted to result in a truncated protein, produced no detectable polypeptide in

Western blot analysis, suggesting that either the polyclonal antibody did not recognize the

truncated polypeptide or the polypeptide is very unstable.


Figure 5.2. Western blot after expression of mutated PBGD constructs in COS cells.

The stability of mutant polypeptides R173W, R173Q, R225C, R225X, and 1073delA were

studied using a pulse-chase experiment. The construct with the mutation R225X did not

produce detectable polypeptide. The other mutated constructs were found to encode a

polypeptide with a stability comparable to the wild type polypeptide, since the signals of all

mutated polypeptides remained similar with the wild type polypeptide at all time points (Figure

5.3.). When polypeptides were chased for 23 hours, both mutant and wild type PBGD were

degraded based on a weaker signal in immunoprecipitation.


Figure 5.3. Pulse-chase experiment of wildtype and mutated PBGD

The half-life of the erythroid form of PBGD is approximately 24 hours if sufficient

porphobilinogen is present to form tetrapyrrole-bound intermediates which are less susceptible

to degrade than the free enzyme (Beaumont et al. 1986). When the amount of porphobilinogen

is inadequate, the polypeptide degrades more rapidly: half of the polypeptide is lost within 10

hours (Beaumont et al. 1986). The housekeeping isoform of PBGD appeared to be more stable

in the absence of substrate than the erythroid isoform, but the half-life of the housekeeping

isoform was not accurately determined (Beaumont et al. 1986). In COS-1 cells transfected with

PBGD cDNA, the enzyme is expressed without regulation and the amount of endogenous

porphobilinogen is probably not sufficient to bind to every molecule formed. In these

circumstances, thus, it is presumed that unbound PBGD is more prevalent than enzyme-

intermediate complex, leading to more instable polypeptide. This hypothesis supports the

results of our experiment, in which the PBGD were clearly degraded after a 23-hour chase.


Figure 5.4. Immunofluorescence of mutated and wild type PBGD after expression.


Based on the immunofluorescence staining, the transfection efficiency using lipofection method

was approximately 20% for each mutated cDNA studied (data not shown), and thus, it was

independent of the construct composition. The construct with the nonsense mutation R225X

was excluded from this experiment, since in the Western blot analysis or in the

immunoprecipitation assay no PBGD polypeptide could be detected. Figure 5.4. shows that in

the immunofluorescence staining the wild type polypeptide is diffusely dispersed in the

cytoplasm. The localization of the mutated polypeptides was indistinguishable from that of the

wild type. Thus, no abnormal accumulation or targeting of the mutated polypeptides was

observed. Moreover, the mutations representing different CRIM classes did not differ from

each other.

While this study is the first in which the properties of mutant PBGD were analyzed using in

vitro expression in eukaryotic cells, the effect of mutations in the PBGD gene on the enzyme

activity has been studied in three previous reports (Delfau et al. 1990, Chen et al. 1994, Ong et

al. 1997) These experiments were performed by expressing the mutated cDNAs of human

PBGD in E. coli. In these studies all mutations resulted in decreased enzyme activity and the

properties of mutant polypeptides were further analyzed by measuring the enzyme activity in

various pH environments (Delfau et al. 1990) or by determining the thermostability of the

polypeptides (Chen et al. 1994). Mutant PBGD appeared to have similar enzyme activities after

eukaryotic and prokaryotic expression, which was expected, since PBGD is a cytosolic enzyme

and is not further processed post-translationally.

Based on the studies of human PBGD mutants (Delfau et al. 1990, Chen et al. 1994, Ong et al.

1997), E. coli mutants (Jordan and Woodcock 1991, Lander et al. 1991), and the three-

dimensional model of the enzyme (Louie et al. 1992, Brownlie et al. 1994), mutations altering

the residues in the vicinity of the active site have always detrimental effect on the enzyme

activity. Amino acid substitutions located elsewhere in the polypeptide have variable

consequences. These mutations are thought either to destabilize the polypeptide or to alter the

protein structure in a way which prevents the substrate reaching the active site. In the present

study the mutant enzyme molecules were as stable as the normal polypeptide after pulse-chase

experiment. However, Chen et al. (1994) showed that mutations C247F and R201W lost half of


the enzyme activity in less than 30 minutes at 65oC while the T1/2 of normal PBGD was 120

minutes. Although this finding cannot be generalized to all the mutations in the PBGD gene, it

suggests that at least some amino acid substitutions actually both destabilize the polypeptide

and decrease enzymatic activity. Interestingly, four mutations located in domain 3 of the

polypeptide have been expressed and all of them had relatively high residual activity of 10-50%

(Chen et al. 1994, VI) after in vitro expression.

5.5. Outcome of mutations

The type and location of mutations resulting in AIP differ from each other considerably and

most of the mutations appear to have a detrimental effect on the normal function of the enzyme.

There is a wide range of mechanisms leading to an inactive enzyme and in this chapter the

potential mechanisms are discussed.

5.5.1. Mutations resulting in premature termination codon

In the case of ten mutations the predicted outcome would be the introduction of a premature

termination codon: IVS1+3G T (see chapter 5.5.3), 97delA, 100C T, insertion of 332 bp in

exon 5 (see chapter 5.5.4.), 417insCA, 445C T, 593G A, 673C T, IVS13-2G A (see

chapter 5.5.3.), and 886C T. The consequences of a premature termination codon on the

function of the enzyme are often dramatic. It is probable that the polypeptide encoded by the

mutant allele is enzymatically totally inactive, since many structures essential for the enzymatic

activity are not translated, and the stability of the polypeptide is probably also influenced by the

missing residues (Brownlie et al. 1994). In addition, the transcript level of the mutant allele is

often decreased (see chapter 5.2.). All nonsense mutations described here are found in CRIM

negative patients, which suggests that mutant polypeptide is not produced or the polypeptide is

unstable (Mustajoki and Desnick 1985).

The outcome of the nonsense mutation R225X (673C T) was studied in detail. The solid-

phase minisequencing method was used to determine the steady state transcript level of the

mutant allele, which was reduced to one fifth of that of normal allele (Table 5.2.). Furthermore,

the mutant transcript levels of the three clinically different patients with this mutation were


similar. One of the patients has had acute attacks, her sister has experienced milder symptoms,

and their mother has always been asymptomatic. Thus, there was no correlation between the

phenotype and the mutant mRNA levels in patients' lymphoblasts. To study the consequences

of the mutation on protein level, the mutation was introduced in the human PBGD cDNA and

expressed in COS cells. The mutant enzyme was not detected by PBGD antibody (Figure 5.2.)

and it had no enzyme activity (Table 5.2.). In conclusion, the mutant transcript level is

remarkably decreased and even if mutant transcript was translated, the polypeptide would be

enzymatically inactive.

5.5.2. Missense mutations

Thirteen base changes were predicted to result in an amino acid substitution. The substituted

residues are highly conserved in different species (Grandchamp et al. 1984, Raich et al. 1986,

Thomas and Jordan 1986, Beaumont et al. 1989, Petricek et al. 1990, Keng et al. 1992, Mohr et

al. 1994, Abdelhak et al. 1997). Of the substituted residues all six arginines and lysine-98 are

invariant and thus completely conserved in the nine species studied (human, murine, rat, feline,

Saccharomyces cerevisiae, Escherichia coli, Pseudomonas aeruginosa, Bacillus subtilis, and

Euglena gracilis), and the remaining five residues are identical at least in mammalian species.

The invariance of the residues would suggest that they are crucial for the proper function of the

enzyme. The consequences of selected mutations were further characterized 1) by determining

the steady transcript level of the mutant allele and 2) in vitro expression of the mutagenized

cDNA construct and subsequent analyses of the polypeptide chains.

The three-dimensional model of PBGD polypeptide enables comparison of the mutant residues

with their corresponding normal residues in the E. coli crystal structure (Louie et al. 1992) and

provides information about the structural and functional consequences of the mutations in the

PBGD polypeptide (Brownlie et al. 1994). In addition, the mutagenesis studies of the E. coli

PBGD have provided valuable information about the function of the enzyme (Jordan and

Woodcock 1991, Lander et al. 1991, Woodcock and Jordan 1994). The consequences of the

missense mutations based on the information obtained from these studies are discussed below.


R26C (76C T). The arginine-26 is located in domain 1 of the PBGD (Figure 2.3.) in the

vicinity of the active cleft. The positively charged side chains of the residue are thought to

interact with the substrate (Lambert et al. 1994). In our expression studies the mutant C26

displayed no enzymatic activity (Table 5.2.). This result is consistent with the mutagenesis

studies in E. coli PBGD: substituting the corresponding residue (R11) results in complete

inactivation of the enzyme (Jordan and Woodcock 1991, Lander et al. 1991), because the

attachment of the first porphobilinogen ring of the substrate (E ES) is inhibited (Jordan and

Woodcock 1991). According to the pulse-chase experiment (Figure 5.2.) the mutant

polypeptide is as stable as the wild type enzyme, which is in agreement with the CRIM positive

status of the patients carrying this mutation.

R167W (499C T). Arginine167 (R149 in E. coli) interacts with the side chain of the cofactor.

Its modification to H149 in the E. coli enzyme leads to an accumulation of the ES intermediate

(enzyme with a single porphobilinogen attached) (Jordan and Woodcock 1991) and a similar

perturbation might also be expected for this mutation (Brownlie et al. 1994). In our expression

studies this mutation displayed a minimal residual activity of 5% (Table 5.2.). This mutation is

found in CRIM positive patients, which is consistent with the pulse-chase experiment, in which

the mutant enzyme was as stable as the wild type enzyme and folded normally, but lacking

function.

R173W (517C T) and R173Q (518G A). The side chain of arginine-173 interacts with the

cofactor and the residue also participates in substrate binding (Shoolingin-Jordan 1995). The

mutants W173 and Q173 were expressed in COS cells and the polypeptides synthesized had no

enzymatic activity even though both polypeptides were detected in the Western blot analysis by

the antibody and in pulse-chase experiments their stability was comparable to the wild type

PBGD (Table 5.2., Figures 5.2 and 5.3.). The mutagenesis studies in E. coli R155 (equivalent

to human R173) also led to severe impairment in substrate binding as well as the release of the

tetrapyrrole product (Jordan and Woodcock 1991, Lander et al. 1991). The mutant transcript

levels compared to the wild type allele in the case of mutations R173W and R173Q were 97%

and 66%, respectively (Table 5.2.).


According to expression studies and determination of transcript levels, thus, the outcome of

mutations substituting R173 are quite similar. The Finnish patients carrying the mutation

R173W have previously been classified as CRIM negative or CRIM positive and patients with

the mutation R173Q as CRIM positive (Mustajoki and Desnick 1985). Our data suggests that

patients carrying the mutation R173W are weakly CRIM positive, i.e. inactive polypeptide is

present, but its amount is so low that it is hardly detectable by rocket immunoelectrophoresis.

This would give us satisfactory explanation for the different CRIM classes in different patients

with the same mutation.

R225G (673C G). Invariant arginine-225 is located on the outer surface of the enzyme (α4-

helix of the subunit 1) and its side chain forms hydrogen bonds to other side chains and also

hydrogen bond to main-chain carbonyl (Brownlie et al. 1994). Furthermore, substituting

arginine with glycine probably destabilizes the protein structure, since, unlike arginine, glycine

does not usually form α-helix structures (Branden and Tooze 1991). The transcript level of the

mutant allele was also determined and it was only slightly decreased (80% of the level of the

wild type allele). In in vitro expression the stability of the mutant polypeptide did not differ

from the wild type PBGD (Figure 5.3.) and, furthermore, the mutated enzyme displayed a

residual activity of 16% (Table 5.2.). Patients with this mutation are CRIM negative, i.e. there

is no inactive enzyme in patients' erythrocytes. The absence of inactive enzyme could be

explained by disruption of interactions and incomplete α-helix formation, which might

destabilize the polypeptide.

K98R (293A G).This highly invariant lysine interacts with dipyrromethane cofactor together

with the neighboring aspartate-99 and four arginines (R149, R150, R167, and R173).

Substitution of the corresponding lysine (K83) by various amino acids in E. coli resulted in an

enzyme that retains less than 1% of its activity (Woodcock and Jordan 1994) and presumably

the consequence of this mutation similar.

R116W (346C T). This substitution is the most common mutation causing AIP in the Dutch

population (Gu et al. 1993b). The arginine residue, located on a short strand linking domains 1

and 2, forms a salt bridge with glutamic acid in position 250 but is not involved in interactions


with the substrate or the cofactor. This mutation has been expressed in E. coli and the residual

PBGD activity was 3.4% (Ong et al. 1997). In addition, the mutagenesis study of the mutant

R101L in E. coli (equivalent to human position 116) displayed 37% residual activity and the

mutation had little effect on either the kinetic parameters of the enzyme or on the formation of

the substrate enzyme complexes (Lander et al. 1991). The patients with this mutation have

CRIM negative status, which is thought to have resulted from the loss of stabilizing interactions

to the glutamic acid residue in position 250 (Brownlie et al. 1994).

R195C (583C T). The patient carrying this mutation is the only affected individual in her

family. Neither parent was a carrier of the mutation and paternity was confirmed using DNA

fingerprint analysis, thus suggesting a de novo mutation. Substituting this arginine inhibits the

assembling of the third porphobilinogen unit to the growing chain (Lander et al. 1991).

C247F (740G T). The cysteine residue is buried in the hydrophobic core of the PBGD

polypeptide and its substitution is speculated to cause a steric disruption of the polypeptide

backbone (Brownlie et al. 1994).

V222M (664G A), L238R (713T G), L278P (833T G) and G280R (838G A). These

residues are conserved only in mammalian species and, furthermore, they do not appear to

interact with other amino acids in the polypeptide (Brownlie et al. 1994). Thus, the mechanism

of how these mutations cause inactivation of the enzyme is not thoroughly clarified. These

substitutions are, however, considered as causative agents for AIP, since 1) no other nucleotide

variation could be identified in the coding region of the PBGD gene by direct sequencing

and/or 2) the DNA analyses of the family members were in agreement with the pedigree

analysis and the results from biochemical analyses.

All mutations identified in CRIM positive patients were arginine substitutions. These arginine

residues form interactions with the substrate or the cofactor and are essential for enzymatic

activity. Minor changes in the polypeptide structure among CRIM positive patients were

expected, since CRIM positivity requires inactive but stable polypeptide which is detected by

a specific antibody. A truncated polypeptide, caused by a premature termination codon or larger


disruption in the nucleotide sequence, would presumably be unstable. However, the possibility

exists that the antibody used in the immunological assays may not recognize it.

5.5.3. Splicing mutations

Four mutations interfere with the normal splicing pattern resulting in aberrant splicing. The

consensus sequence for RNA splicing is known (Table 5.3.) but mechanisms for a splicing

defect have not been thoroughly clarified. However, studies of different types of mutations at

the splice sites have provided useful information about aberrant splicing (Krawczak et al. 1992,

Nakai and Sakamoto 1994)

Table 5.3. Consensus sequences for RNA splicing.a

5'---CAGgu

aagt------a------

uuuuuuuuuuuuncag

G---3'

A g cccccccccccc u A

5' splice site (donor site) branch point A 3' splice site (acceptor site)a Adapted from (Alberts et al. 1994). Intronic sequence in lowercase and

exonic sequence in uppercase letters. n, any nucleotide

Three of the splicing mutations are located at the 5' donor splice site. In the case of the mutation

IVS1+3G T, the cryptic splice site is present 67 nucleotides away from the authentic splice

site. This finding is in agreement with the previous survey, in which most of the cryptic splice

sites activated by mutations are located relatively near, usually within 100 nucleotides, to the

authentic splice site (Nakai and Sakamoto 1994). The rest of the gene is transcribed normally,

but due to the uneven amount of nucleotides in the inserted fragment, a frame shift appears at

the beginning of exon 3 introducing a premature termination codon in exon 5. The length of the

predicted polypeptide is 73 amino acids and only the first exon would be translated normally.

Because the mutant polypeptide is dramatically truncated, it can be predicted to be

enzymatically inactive.

The mutation 33G T hits the last nucleotide of exon 1. The substitution does not modify the

amino acid and, although definitive proof is missing, it is thought to be responsible for

abnormal splicing (Grandchamp et al. 1989b, Kauppinen 1992b). Due to the tissue-specificity,


the erythrocyte PBGD activity in patients with mutations 33G T and IVS1+3G T is normal

and these mutations cause the variant form of AIP.

Exon skipping is the most frequent consequence of a splice mutation at either the 5' or 3' splice

site (Nakai and Sakamoto 1994), and it is also the predicted outcome of the mutation 86A T.

Interestingly, this base change would also result in the amino acid substitution Q29L if the

normal splicing was not affected. If no alternative sites with sufficient homology to the

consensus sequence exist in the vicinity, either exon skipping or greatly reduced production of

normal transcripts seem to be the predominant phenotypic consequences (Krawczak et al.

1992). In this case exon skipping is probably due to a lack of the potential cryptic splice site in

the vicinity of the 5' splice site of intron 3 and, as a result, 18 amino acids encoded by exon 3

are missing from the predicted PBGD polypeptide. The consequence of a missing exon 3 for

the function of the PBGD enzyme is most probably detrimental, since the exon codes for

residues (for example R26) which interact with the substrate (Jordan and Woodcock 1991,

Brownlie et al. 1994).

At the 3' splice site, the adenine at position -2 is highly conserved and this nucleotide is

significant for splicing events, since substitutions of this nucleotide are more frequent than

theoretical models predict (Krawczak et al. 1992). Intron retention, however, is the most

infrequent pattern of aberrant splicing (Nakai and Sakamoto 1994). According to the ’exon

definition hypothesis’, a model derived from experimental analyses (Niwa et al. 1992), intron

retention is permitted when the intron is small enough to satisfy the exon length limitation. In

the case of the mutation IVS13-2A G, the total length of exon 13, intron 13, and exon 14

includes only 204 nucleotides, which agrees well with this hypothesis. A premature termination

is introduced in intron 13 and the predicted polypeptide contains 275 normally translated amino

acids followed by 26 amino acids encoded by intron 13. In the PBGD polypeptide, exons 13

and 14 code for residues in the subunit β2 of the third domain (Brownlie et al. 1994). Similarly,

the nonsense mutation in exon 14 (W283X) deletes 78 residues from domain 3 and results in a

truncated polypeptide but yet retains ~10% of the normal expressed PBGD activity in E. coli

(Chen et al. 1994). The consequence of mutation IVS13-2A G on the enzyme properties may

be similar.


5.5.4. Other mutations

Insertion of an Alu element. In SSCP analysis covering exons 5 to 7 a mobility shift was

identified in a sample of a patient belonging to a large AIP family (Figure 5.5.). The band

migrating more slowly than normal DNA strands was excised from the SSCP gel, diluted, and

reamplified. The PCR product was sequenced revealing a sequence homologous to an Alu

sequence. An extra fragment of 1019 bp in size could also be demonstrated in PCR covering

exons 5 to 7 from genomic DNA samples of five patients known to have low erythrocyte PBGD

activity, suggesting that an Alu insertion of ~350 bp in exon 5 of the PBGD gene was

responsible for AIP in this family. Simple amplification of exons 5 to 7 can easily be used in

the molecular diagnosis of this insertion (Figure 5.5.). It is of note that this additional fragment

could also be demonstrated by amplification of exon 5 alone but not in PCR reaction over

exons 3 to 5.

Figure 5.5. A) SSCP analysis showing an insertion which results in a mobility shift(arrow). B) PCR covering exons 5 to 7. Genomic DNA of the patients with Aluinsertation demonstrate both normal (687 bp) and inserted (1019 bp) alleles,whereas healthy controls demonstrate a normal allele. Leftmost lane, DNAmolecular weight maker VI (Boehringer Mannheim, Germany). N, healthy control,P, AIP patient.

A 333 bp Alu insertion in exon 5 was characterized after subcloning and sequencing the two

alleles of different size separately. The mutant allele included a 13 bp target site duplication and

3' terminal poly(A) tract in the antisense orientation. The sequence comparison of the inserted

Alu element with a database for repeated elements (Pythia, Jurka 1993) showed that it belongs

to the Ya5 subfamily. This subgroup is one of the youngest and currently most active Alu

subfamilies in evolution. There are no earlier reports of Alu insertions resulting in AIP and


none of the six Alu repeats located in the intronic areas of the PBGD gene belong to the same

subfamily (Yoo et al. 1993).

The predicted polypeptide contains 64 normally translated amino acids followed by 13 amino

acids not normally found in the PBGD polypeptide. A premature termination codon, which is

introduced at the beginning of the insertion, is located at the first codon after the 42 thymidines

which form the polyadenine tail of the Alu element. Amplification and sequencing of the

reverse transcribed total RNA extracted from a patient's lymphoblast cell line exposed only the

wild type allele.

The expression of the mutated and wild type PBGD constructs in COS-1 cells showed that the

insertion of the Alu element resulted in a total loss of the enzyme activity, which was expected

since nearly all structures crucial for the enzymatic function of the PBGD are missing

(Shoolingin-Jordan 1995). The TfiI restriction site located in exon 3 was removed from the

construct for the cloning purpose. This base change, however, did not alter the amino acid

sequence. The PBGD activity produced by this construct was close to normal, i.e. 88% of the

wild type activity. When the polyclonal rabbit anti-human-PBGD antibody was used to identify

the PBGD polypeptide in Western analysis, no mutant polypeptide could be detected. In

contrast, the wild type PBGD as well as the PBGD construct, in which the TfiI restriction site

was removed, produced a detectable polypeptide of normal size (42 kD).

Insertion of an Alu element into the coding sequence of a gene is an infrequent phenomenon:

only 17 coding sequences have been previous reported to be disrupted by an Alu repeat

(Makalowski et al. 1994). Furthermore, only eight of these Alu insertions have been associated

with a disease or a loss of biological activity. The disruption is most commonly caused by a

mutation splicing an intronic Alu sequence into the coding region of mRNA. Retroposition of

an Alu element into an exon occurs more rarely, and in that case, the Alu cassette is usually in

the sense orientation (Makalowski et al. 1994).

However, the PBGD Alu cassette is incorporated directly via retroposition into exon 5 in the

antisense orientation.


1073delA. A deletion of one nucleotide is located 11 base pairs upstream of the termination.

The consequence of this deletion is a frame shift which removes the normally utilized

termination codon and does not create a new one before the polyadenylation signal. If the

translation stops at the polyadenylation signal, the length of the polypeptide would be 448

amino acids instead of the 361 of the wild type polypeptide. The first 357 amino acids of the

mutant polypeptide are predicted to be identical with the wild type enzyme and, thus, it

contains all the components known to be essential for the function of the PBGD.

When the transcript level of the mutant allele was determined, the results suggested that the

mutant allele is transcribed normally (Table 5.2.). However, the mutant mRNA appeared to get

degraded more rapidly than the transcript from the wild type allele during storage at -80oC. This

mutation was studied further by expressing the mutant PBGD-cDNA in COS cells. The mutant

clone displayed 50% residual activity (Table 5.2.). The non-coding region of the construct,

however, differed from the human PBGD gene. In the mutated construct the last 46 residues of

the synthesized polypeptide were encoded by the 3'-UTR region of the PBGD cDNA and the

vector sequence and a termination codon is introduced after 404 amino acids. This polypeptide

encoded by the construct is, thus, 44 amino acids shorter than the predicted mutant polypeptide

of the patient. The stability of the polypeptide encoded by the mutant construct was comparable

to the normal polypeptide in the pulse-chase experiment. However, this finding does not

exclude the possibility that mutant polypeptide would actually be more unstable in vivo.

5.6. Molecular genetics of AIP in the Finnish population

The population of Finland has been isolated during the past centuries and many diseases which

are rare in other countries are relatively common in Finland (de la Chapelle 1993).

Furthermore, there is an obvious founder effect in the case of many diseases; one mutation is

prevalent and is found in almost every affected individual. Studies from Sweden, the

Netherlands and Switzerland, suggest that a founder effect is present in these countries also in

the case of AIP (Lee and Anvret 1991, Gu et al. 1993b, Schneider-Yin et al. 1999). However,

the molecular defects are heterogeneous in the Finnish AIP patients, most of the identified

mutations are family specific (Table 5.1.). The R173Q mutation was the underlying reason for


AIP in four families. The pedigree of these families have been traced back for at least three

generations and no links could be identified between ancestors. However, three of the families,

originate from the same municipality (R173Q, number 14 in Figure 5.6.), implying that they

most probably are related to each other. In addition, the two families with mutation R149X are

originally from neighboring villages, which also suggests a common ancestor. Thus, there is a

minor founder effect among the Finnish AIP families. Also in France and in the United

Kingdom the molecular genetic background is highly heterogeneous and no founder effect has

been identified in these countries (Puy et al. 1997b, Whatley et al. 1999).


Figure 5.6. The origin of the Finnish AIP families. The numbers refer to mutations in Table 5.1.A and B: Origin of AIP families with yet unidentified genetic defect.


The mutation 1073delA was found in a patient who belongs to the Skolt community. The Skolts

are Saamians who live in Northern Lappland. They have been very isolated for centuries and

form a homogenic population. Thus, it was possible, that the prevalence of AIP among Skolts

would be higher than in the rest of the Finnish population. To test this hypothesis, 94 DNA

samples from members of the Skolt community were screened for this mutation using the

minisequencing method (data not shown). As a result, the mutation could be identified in two

additional samples. These two individuals belonged to the same family as the index patient and,

furthermore, they were previously classified as AIP patients based on biochemical analyses. All

other samples were negative for this mutation and, thus, the conclusion was that prevalence of

AIP was not considerably higher in the Skolt community compared to the rest of the Finnish

population.

5.5. DNA diagnosis of AIP

The identification of underlying genetic defects now allows a reliable DNA-based diagnostics

of AIP in each family, which is in routine use when AIP status of asymptomatic family

members is determined. At least two separate analyses are carried out for each DNA sample.

Digestion with a restriction enzyme is used whenever possible, direct sequencing is performed

in both directions and minisequencing is also available in the case of some mutations.

The possibility of determining the genetic defect has also enabled the evaluation of the value of

biochemical methods in AIP diagnosis. Detailed screening for a mutation was tested in three

families representing different subtypes of AIP (Table 5.4.). The samples of a total of 81 family

members, among them 28 individuals with mutations were analyzed using both DNA and

biochemical methods. Biochemical methods (erythrocyte PBGD activity, urinary PBG and

ALA) failed to detect 25% (7/28) of patients. Furthermore, four out of 53 (8%) healthy family

members were falsely diagnosed as AIP carriers, but this may be due to the relatively low

PBGD activity from both parents' erythrocytes although the patients' father is apparently

healthy.


Table 5.4. Evaluation of biochemical methods in AIP diagnosis

Mutation a PBGDactivity b

Total number ofanalyzed family

members

No. ofmutationcarriers

False negativeresult in

biochemical tests

False positiveresult in

biochemical tests

33G T (-) N 30 10 2 0

499C T (+) V 28 12 3 4

673C T (-) V 23 6 2 0a CRIM status in parenthesisb PBGD activity in erythrocytes; N, normal activity; V, low activity

The feasibility of enzymatic screening in AIP diagnosis has also been evaluated in large

material of French AIP patients and their family members (Puy et al. 1997b). As a result,

determination of PBGD activity gave wrong diagnosis in 16% (45/280). However, if patients

with variant AIP were excluded from the analysis, the AIP gene-carrier status was correctly

stated in 240/252 (95%) cases. Thus, the biochemical methods have their limitations and DNA

analysis should be used whenever available in AIP diagnosis during the asymptomatic phase.

SUMMARY AND CONCLUSIONS 66

6. SUMMARY AND CONCLUSIONS

In the present work the molecular genetics of Finnish AIP patients was characterized. The

results of the studies and their conclusions can be summarized as follows:

• Twenty-two mutations were identified in the PBGD gene resulting in AIP. Together with

the previously identified genetic defects, the 26 characterized mutations cover 38 (95%)

of a total of 40 unrelated Finnish AIP families. Despite the heterogeneity at the molecular

level, the clinical manifestations of AIP are relatively uniform and no evidence emerged

for genotype-phenotype correlation.

• A specific diagnosing method based on DNA techniques was developed for each

mutation. The DNA diagnosis should always be used in screening of family members,

since biochemical methods fail to detect 10-20% of AIP patients.

• Mutations in the PBGD gene were screened using two different methods: DGGE and

SSCP. Both methods were useful and were able to detect most genetic defects, but the

sensitivity of DGGE was considerably higher.

• The steady state mRNA levels of six mutations were analyzed using solid-phase

minisequencing. The mutant mRNA levels in lymphocytes varied from 5 to 95% of the

corresponding wild type allele levels and all mutations, except the missense mutation

R173W in exon 10, affected the steady state transcript levels of the mutant allele. The

decreased mutant transcript level did not correlate either to CRIM class, to the location

of the disease causing mutation in the PBGD gene, or to the clinical phenotype of AIP.

• Using in vitro expression in COS-1 cells, eight mutations identified previously in Finnish

AIP patients were analyzed. All mutations resulted in a decrease in PBGD activity, and

six of the mutated enzymes displayed only minimal residual activity of 0-5%, confirming

the causality of the amino acid substitution and the low PBGD activity. The mutated

polypeptides were as stable as the normal PBGD, with the exception of truncated

polypeptide (mutation R225X) which could not be detected with the polyclonal antibody.

Furthermore, no abnormalities in the intracellular location of mutated polypeptides could

be observed by immuno-fluorescence.

ACKNOWLEDGEMENTS67

7. ACKNOWLEDGEMENTS

This study was carried out during years of 1993-1999 at the Department of Medicine, Divisionof Endocrinology, University of Helsinki and at the Department of Human Molecular Genetics,National Public Health Institute. Professor Marja-Riitta Taskinen, M.D., the Head of theDivision of Endocrinology is highly acknowledged for providing me excellent laboratoryfacilities and for continuous support in my efforts.

I express my greatest gratitude to my supervisors Raili Kauppinen and Leena Palotie-Peltonen.Raili has patiently taught me all the laboratory skills and the scientific way of thinking,although I was not always an especially quick learner. Her overwhelming enthusiasm towardsporphyrias and molecular genetics has been contagious. Leena amazes me time and time againwith her incredible memory and thorough knowledge of molecular genetics. Even though herschedule is very tight, she always found a time for me in her diary. After a meeting with Leenaall problems whatsoever seemed much smaller.

Professors Marja-Liisa Savontaus and Jean-Charles Deybach reviewed this thesis. They gaveconstructive criticism and noted important weaknesses in it. I appreciate their carefulexamination of this manuscript and most of all their positive attitude towards my work.

I am more than grateful to my uncle Pertti Mustajoki, M.D., who originally introduced me tothe world of porphyrias. Pertti's exceptionally wide perspective over the disorders of the hememetabolism is admirable. His supportive attitude towards my research has encouraged merepeatedly. Furthermore, our discussions have greatly influenced my way of working not onlyas a researcher but also as a practicing physician.

I would like to warmly thank all my collaborators Anu Wartiovaara (Suomalainen), M.D.,Minna Laine (Peltola), M.D., Maija Lahtela-Kakko, Ph.D., and the members of the DanishPorphyria Research Laboratory: Henrik Nissen, Ph.D., Niels Erik Petersen, Ph.D., TorbenHansen, Ph.D., and Mogens Hørder, Ph.D. Their excellent knowledge and skills haveconsiderably helped me during this study. Professor Bernard Grandchamp, M.D. isacknowledged for providing us with the PBGD cDNA and Dr. Ylva Floderus, PhD., providedus with PBGD antibody, which is also highly appreciated.

I warmly thank Ms. Hannele Pihlaja and Ms. Helena Ahola for their excellent technicalassistance and always positive and flexible attitude. The intensive moments of laboratory workwere made very pleasant when I could engage in interesting conversations concerning almosteverything in the whole wide world. Although I did not have any direct collaboration with Dr.Kaisa Timonen, M.D., I found her presence in the porphyria research group very pleasant.Professor Raimo Tenhunen, M.D. is acknowledged for providing the facilities for enzymeactivity measurements.

The colleagues and laboratory personnel in the Scientific Laboratory of the Helsinki UniversityCentral Hospital are warmly acknowledged for giving relaxing and hilarious company duringthe coffee-breaks, which too often were extended to coffee-hours. The atmosphere in thecoffee-room of the Scientific Laboratory was exceptional, and that repeatedly cheered me upafter an unsuccessful experiment. Especially I want to thank Ms. Sirkka-Liisa (Kikka)

ACKNOWLEDGEMENTS 68

Runeberg, whose sense of humor and exceptional ability to listen have made a deep and ever-lasting impact on me.

I want to express my warmest gratitude to my other uncle professor Arto Mustajoki, Ph.D. Theweekly squash matches, followed by the 'hair-drying', i.e. beer or two in the pub nearby, areunforgettable. Although the world did not become any better place to live despite our seriousefforts, our conversations offered me fresh perspectives to the scientific world, especially fromthe linguistic and administrative point of view.

I have spent many breathtaking moments with the running team of the Scientific laboratory.The gentle pressure of the other regular members of the team, Satu Vehkavaara, TatuMiettinen, Jaakko Kaukonen, Nina Lindbohm, and Heikki Relas, made me to take care of myphysical wellbeing. Besides, no one else but a young researcher can really understand thedifficulties of a young researcher, and our conversations during the weekly runs were often verytherapeutic. Furthermore, I am pleased that the Scientific Losers Club was finally founded,although the two founder members, Jaakko and I, do not actually meet the criteria for themembership any more.

I have a wonderful family. My parents Erkki Mustajoki and Päivi Lindstedt have given me allthe love and support I have ever needed. The importance of my two sisters, HenriikkaClarkeburn and Iida-Maaria Lindstedt, in my life cannot be exaggerated. The supportiveattitude of Risto Lindstedt, Jeffrey Clarkeburn and my parents-in-law, Anna-Liisa and OlliLaurila, is also highly appreciated.

Finally, I am more than grateful to my wife Ulla. She has been there during all the phases ofthis work. She has patiently tolerated me when all went wrong in the lab and with her I haveshared the moments of success. No words are sufficient to express my love to her.

This work was supported by grants from University of Helsinki, Academy of Finland, theResearch Funds and the Clinical Research Institute of the Helsinki University Central Hospital,Emil Aaltonen Foundation, the Paulo Foundation, the Instrumentarium Foundation, the Scienceand Research Foundation of Farmos Medical Company, the Aarne Koskelo Foundation, and theFinnish Medical Society Duodecim.

Helsinki, October 1999

REFERENCES69

8. REFERENCES

Abdelhak S, Kalatzis V, Heilig R, Compain S, Samson D, Vincent C, Levi-Acobas F, Cruaud C, Le Merrer M,Mathieu M, König R, Vigneron J, Weissenbach J, Petit C, Weil D. Clustering of mutations responsible for branchi-oto-renal (BOR) syndrome in the eyes absent homologous region (eyaHR) of EYA1. Hum Mol Genet 6:2247-2255,1997.

Alberts B, Bray D, Lewis J, Raff M, Roberts K, Watson JD. Molecular Biology of the Cell. Garland Publishing Inc.,New York, 1994.

Anderson PM, Reddy RM, Anderson KM, Desnick RJ. Characterization of the porphobilinogen deaminasedeficiency in acute intermittent porphyria. J Clin Invest 68:1-12, 1981.

Andersson C, Lithner F. Hypertension and renal disease in patients with acute intermittent porphyria. J Intern Med236:169-175, 1994.

Andersson C, Bjersing L, Lithner F. The epidemiology of hepatocellular carcinoma in patients with acute intermittentporphyria. J Int Med 240:195-201, 1996.

Andersson C. Acute intermittent porphyria in Northern Sweden. A population-based study. Academic dissertation.Departments of Family Medicine and Medicine, University of Umeå, Sweden. 1997.

Baserga SJ, Benz EJJ. Beta-globin nonsense mutation: deficient accumulation of mRNA occurs despite normalcytoplasmic stability. Proc Natl Acad Sci USA 90:482-486, 1992.

Beaumont C, Grandchamp B, Bogard M, de Verneuil H, Nordmann Y. Porphobilinogen deaminase is unstable in theabsence of its substrate. Biochim Biophys Acta 882:384-388, 1986.

Beaumont C, Porcher C, Picat C, Nordmann Y, Grandchamp B. The mouse porphobilinogen deaminase gene. J BiolChem 264:14829-14834, 1989.

Berk PD, Blaschke TF, Scharschmidt BF, Waggoner JG, Berlin NI. A new approach to quantitation of the varioussources of bilirubin in man. J Lab Clin Med 12:389-390, 1976.

Bissel L. Laboratory evaluation in porphyria. Semin Liv Dis 2:100-107, 1982.

Bonkovsky HL. Advances in understanding and treating 'The little imitator', acute porphyria. Gastroenterology105:590-594, 1993.

Branden C, Tooze J. Introduction to protein structure. Garland Publishing Inc., New York, 1991.

Brownlie PD, Lambert R, Louie GV, Jordan PM, Blundell TM, Warren MJ, Cooper JB, Wood SP. The three-dimensional structures of mutants of porphobilinogen deaminase: Toward an understanding of the structural basis ofacute intermittent porphyria. Prot Sci 3:1644-1650, 1994.

Carter MS, Li S, Wilkinson MF. A splicing-dependent regulatory mechanism that detects translation signal. EMBOJ 15:5965-5975, 1996.

de la Chapelle A. Disease gene mapping in isolated human populations: the example of Finland. J Hum Genet30:857-865, 1993.

Chen C-H, Astrin KH, Lee G, Anderson KE, Desnick RJ. Acute intermittent porphyria: identification and expressionof exonic mutations in the hydroxymethylbilane synthase gene. J Clin Invest 94:1927-1937, 1994.

Cheng J, Maquat LE. Nonsense codons can reduce the abundance of nuclear mRNA without affecting the abundanceof pre-mRNA or the half-life of cytoplasmic mRNA. Mol Cell Biol 10:5215-5225, 1993.

REFERENCES 70

Chirgwin JM, Przbyla AE, McDonald RJ, Rutter WJ. Isolation of biologically active ribonucleic acid from sourcesenriched in ribonuclease. Biochemistry 18:5294-5299, 1979.

Chretien S, Dubart A, Beaupain D, Raich N, Grandchamp B, Rosa J, Goossens M, Romeo PH. Alternativetranscription and splicing of the human porphobilinogen deaminase results either in tissue-specific or in house-keeping expression. Proc Natl Acad Sci USA 85:6-9, 1988.

Cooper DN. Human gene mutations affecting RNA processing and translation. Ann Med 25:11-17, 1993.

Daimon M, Morita Y, Yamatani K, Igarashi M, Fukase N, Ohnuma H, Sugiyama K, Ogawa A, Hideo M, Manaka H,Sasaki H. Two new polymorphisms in introns 2 and 3 of the human porphobilinogen deaminase gene. Hum Genet92:549-553, 1993a.

Daimon M, Yamatani K, Igarashi M, Fukase N, Morita Y, Ogawa A, Tominaga M, Sasaki H. Acute intermittentporphyria caused by a G to C mutation in exon 12 of the porphobilinogen deaminase gene that results in exonskipping. Hum Genet 92:549-553, 1993b.

Daimon M, Yamatani K, Igarashi M, Fukase N, Morita Y, Ogawa A, Tominaga M, Sasaki H. Acute intermittentporphyria caused by a single base insertion of C in exon 15 of the porphobilinogen deaminase gene that results in aframe shift and premature stopping of translation. Hum Genet 93:533-537, 1994.

Dean G. The porphyrias. A story of inheritance and environment. Pitman Medical Publishing Co., London, 1963.

Delfau M, Picat C, de Rooij F, Hamer K, Bogard M, Wilson J, Deybach J, Nordmann Y, Grandchamp B. Twodifferent point G to A mutations in exon 10 of the porphobilinogen deaminase gene are responsible for acuteintermittent porphyria. J Clin Invest 86:1511-1516, 1990.

Delfau M, Picat C, de Rooij F, Voortman G, Deybach J, Nordmann Y, Grandchamp B. Molecular heterogeneity ofacute intermittent porphyria: identification of four additional mutations resulting in the CRIM-negative subtype ofthe disease. Am J Hum Genet 49:421-428, 1991.

Desnick RJ, Ostasiewicz LT, Tishler PA, Mustajoki P. Acute intermittent porphyria: characterization of a novelmutation in the structural gene for porphobilinogen deaminase. J Clin Invest 76:865-874, 1985.

Deybach J-C, Puy H. Porphobilinogen deaminase gene structure and molecular defects. J Bioenerg Biomembr27:197-205, 1995.

Elder GH, Hift RJ, Meissner PN. The acute porphyrias. Lancet 349:1613-1617, 1997.

Felgner PL, Gadek TR, Holm M, Roman R, Chan HW, Wenz M, Northrop JP, Ringold GM, Danielsen M.Lipofection: a highly efficient, lipid mediated DNA-transfection procedure. Proc Natl Acad Sci USA 84:7413-7417,1987.

Ford RE, Ou C-N, Ellefson RD. Assay of erythrocyte uroporphyrinogen I synthase activity, with porphobilinogen assubstrate. Clin Chem 26:1182-1185, 1980.

Fujita H, Yamamoto M, Hayashi N, Sassa S. Erythroleukemia differentiation. Distinctive responses of the erythroid-specific and the nonspecific δ-aminolevulinate synthase mRNA. J Biol Chem 266:17494-17502, 1991.

Goldberg A. Acute intermittent porphyria: A study of 50 cases. Q J Med 28:183-209, 1959.

Goldberg A, Rimington C. Diseases of porphyrin metabolism. Charles C. Thomas Springfield, Illinois, 1962.

Grandchamp B, Romeo PH, Dubert A, Raich N, Rosa J, Nordmann Y, Goossens M. Molecular cloning of a cDNAsequence complementary to porphobilinogen deaminase mRNA from rat. Proc Natl Acad Sci USA 81:5036-5040,1984.

REFERENCES71

Grandchamp B, de Verneuil H, Beaumont C, Chretien S, Walter O, Nordmann Y. Tissue-specific expression ofporphobilinogen deaminase: two isoenzymes from a single gene. Eur J Biochem 162:105-110, 1987.

Grandchamp B, Picat C, de Rooij F, Beaumont C, Wilson P, Deybach J-C, Nordmann Y. A point mutation G-A inexon 12 of the porphobilinogen deaminase gene results in exon skipping and is responsible for acute intermittentporphyria. Nucleic Acids Res 17:6637-6649, 1989a.

Grandchamp B, Picat C, Kauppinen R, Mignotte V, Peltonen L, Mustajoki P, Romeo PH, Goossens M, NordmannY. Molecular analysis of acute intermittent porphyria in a Finnish family with normal erythrocyte porphobilinogendeaminase. Eur J Clin Invest 19:415-418, 1989b.

Grandchamp B, Picat C, Mignotte V, Wilson JHP, TeVelde K, Sandkuyl L, Romeo PH, Goossens M, Nordmann Y.Tissue-specific splicing mutation in acute intermittent porphyria. Proc Natl Acad Sci USA 86:661-664, 1989c.

Grandchamp B, Picat C, de Rooij F, Delfau MH, Gu XF, Deybach J-C, Wilson JPH, teVelde K, Nordmann Y.Porphobilinogen deaminase gene abnormalities in acute intermittent porphyria. International meeting on porphyrinmetabolism and iron metabolism, Papendal, the Netherlands, 1992.

Granick S. Induction of the synthesis of 5-ALA synthetase in liver parenchymal cells in culture by chemicalsinducing acute porphyria. J Biol Chem 238:2247-2250, 1963.

Granick S. The induction in vitro of the synthesis of delta-aminolevulinic acid synthetase in chemical porphyria: Aresponse to certain drugs, sex hormones and foreign chemicals. J Biol Chem 241:1359-1375, 1966.

Grompe M. The rapid detection of unknown mutations in nucleic acids. Nature Genet 5:111-117, 1993.

Gu XF, Lee JS, Delfau MH, Grandchamp B. PCR detection of a G/T polymorphism at exon 10 of theporphobilinogen deaminase gene (PBG-D). Nucleic Acids Res 19:1966, 1991.

Gu XF, de Rooij F, Voortman G, TeVelde K, Nordmann Y, Grandchamp B. High frequency of mutations in exon 10of the porphobilinogen deaminase gene in patients with a CRIM-positive subtype of acute intermittent porphyria. AmJ Hum Genet 51:660-665, 1992.

Gu XF, de Rooij F, de Baar E, Bruyland M, Lissens W, Nordmann Y, Grandchamp B. Two novel mutations of theporphobilinogen deaminase gene in acute intermittent porphyria. Hum Mol Genet 2:1735-1736, 1993a.

Gu XF, de Rooij F, Lee J-S, Te Velde K, Deybach JC, Nordmann Y, Grandchamp B. High prevalence of a pointmutation in the porphobilinogen deaminase gene in Dutch patients with acute intermittent porphyria. Hum Genet91:128-130, 1993b.

Gu XF, de Rooij F, Voortman G, TeVelde K, Deybach J-C, Nordmann Y, Grandchamp B. Detection of elevenmutations causing acute intermittent porphyria using denaturing gradient gel electrophoresis. Hum Genet 93:47-52,1994.

Higuchi R. Simple and rapid preparation of samples for PCR. In: Ehrlich HA, eds. PCR Technology. Principles andApplications for DNA Amplification. New York: Stockton Press. pp. 31-38, 1989.

Jagadeeswaran P, Forget BG, Weissman SM. Short interspersed repetitive DNA elements in eucaryotes: transposableDNA elements generated by reverse transcription of RNA pol III transcripts? Cell 26:141-142, 1981.

Jordan PM, Warren MJ. Evidence for a dipyrromethane cofactor at the catalytic site of E. coli porphobilinogendeaminase. FEBS Lett 225:87-92, 1987.

Jordan PM, Woodcock SC. Mutagenesis of arginine residues in the catalytic cleft of Escherichia coliporphobilinogen deaminase that affects dipyrromethane cofactor assembly and tetrapyrrole chain initiation andelongation. Biochem J 280:445-449, 1991.

REFERENCES 72

Jurka J. A new subfamily of recently retroposed human Alu repeats. Nucleic Acids Res 21:2252, 1993.

Kappas A, Sassa S, Galbraith RA, Nordmann Y. The porphyrias. In: Scriver CR, Beaudet A, Sly WS, Valle D, eds.The metabolic and molecular bases of inherited diseases. New York: McGraw-Hill. pp. 2116-2127, 1995.

Karttunen L, Lönnqvist L, Godfrey M, Peltonen L, Syvänen A-C. An accurate method for comparing transcript oftwo alleles or highly homologous genes: application to fibrillin transcripts in Marfan patients' fibroblasts. GenomeRes 6:392-403, 1996.

Kauppinen R. Prognosis of acute porphyrias and molecular genetics of acute intermittent porphyria in Finland.Academic dissertation. Department of Human Molecular Genetics, National Public Health Institute and ThirdDepartment of Medicine, University of Helsinki, Finland. 1992a.

Kauppinen R. Single-strand conformation polymorphism (SSCP) analysis applied to the diagnosis of acuteintermittent porphyria. Mol Cell Probes 6:527-530, 1992b.

Kauppinen R, Mustajoki P. Prognosis of acute intermittent porphyria: occurrence of acute attacks, precipitatingfactors and associated disease. Medicine 71:1-13, 1992.

Kauppinen R, Peltonen L, Pihlaja H, Mustajoki P. CRIM-positive mutations of acute intermittent porphyria inFinland. Hum Mutat 1:392-396, 1992.

Keng TC, Richard C, Larocque R. Structure and regulation of yeast HEM3, the gene for porphobilinogen deaminase.Mol Gen Genet 234:233-243, 1992.

Krawczak M, Reiss J, Cooper DN. The mutational spectrum of single base pair substitutions in mRNA splicejunctions of human genes: causes and consequences. Hum Genet 90:41-54, 1992.

Laemmli U. Cleavage of structural proteins during the assembly of the head of bacteriophage T4. Nature 227:680-685, 1970.

Lambert R, Brownlie PD, Woodcock SC, Louie GV, Cooper JB, Warren MJ, Jordan PM, Blundell TL, Wood SP.Structural studies on porphobilinogen deaminase. In: Chadwick DJ, Ackrill K, eds. The Biosynthesis of thetetrapyrrole pigments. Ciba Foundation Symposium 180. Chichester: Wiley. pp. 97-110, 1994.

Lamon JM, Frykholm BC, Tschudy DP. Screening tests in acute porphyria. Arch Neurol 34:709-712, 1977.

Lander M, Pitt AR, Alefounder PR, Bardy D, Abell C, Battersby AR. Studies on the mechanism ofhydroxymethylbilane synthase concerning the role of arginine residues in substrate binding. Biochem J 275:447-452,1991.

Langenskiöld F. Om hematoporfyri med ileusliknande symtom. Finska Läk-Sällsk Handl 70:241, 1928.

Lannfelt L, Wetterberg L, Gellerfors P, Lilius L, Floderus Y, Thunell S. Mutations in acute intermittent porphyriadetected by ELISA measurement of porphobilinogen deaminase. J Clin Chem Clin Biochem 183:857-862, 1989a.

Lannfelt L, Wetterberg L, Lilius L, Thunell S, Gellefors P. ELISA for measuring porphobilinogen deaminase inhuman erythrocytes. Clin Chim Acta 183:227-238, 1989b.

Law WK, Choy KW, Lam CW. Novel single nucleotide polymorphism (9678G -> A) for linkage analysis of acuteintermittent porphyria. Clin Chem 45:308-309, 1999.

Lee GY, Astrin KH, Desnick RJ. Acute intermittent porphyria: A single-base deletion and a nonsense mutation in thehuman hydroxymethylbilane synthase gene, predicting truncations of the enzyme polypeptide. Am J Med Genet58:155-158, 1994.

REFERENCES73

Lee JS, Anvret M. A PstI polymorphism for the human porphobilinogen deaminase gene (PBG). Nucleic Acids Res15:6307, 1987.

Lee JS, Anvret M, Lindsten J, Lannfelt L, Gellerfors P, Wetterberg L, Floderus Y, Thunell S. DNA polymorphismswithin the porphobilinogen deaminase gene in two Swedish families with acute intermittent porphyria. Hum Genet79:379-381, 1988.

Lee J, Grandchamp B, Anvret M. A point mutation of the human porphobilinogen deaminase gene in a Swedishfamily with acute intermittent porphyria. Am J Hum Genet 47[Suppl]:A162, 1990.

Lee J. Molecular genetic investigation of the human porphobilinogen deaminase gene in acute intermittent porphyria.Academic dissertation. Karolinska Institute, Stockholm, Sweden. 1991a.

Lee JS. Alternative dideoxy sequencing of double-stranded DNA by cyclic reactions using Taq polymerase. DNACell Biol 10:67-73, 1991b.

Lee J, Anvret M. Identification of the most common mutation within the porphobilinogen deaminase gene in Swedishpatients with acute intermittent porphyria. Proc Natl Acad Sci USA 88:10912-10915, 1991.

Lindberg RLP, Porcher C, Grandchamp B, Ledermann B, Bürki K, Brandner S, Aguzzi A, Meyer UA.Porphobilinogen deaminase deficiency in mice causes a neuropathy resembling that of human hepatic porphyria.Nature Genet 12:195-199, 1996.

Lindberg RLP, Martini R, Bamgartner M, Erne B, Borg J, Zielasek J, Ricker K, Steck A, Toyka KV, Meyer UA.Motor neuropathy in porphobilinogen deaminase-deficient mice imitates neuropathy of human acute porphyria. JClin Invest 103:1127-1134, 1999.

Linet MS, Gridley G, Nyren O, Mellemkjaer L, Olsen JH, Keehm S, Adami HO, Fraumeni JF. Primary liver cancer,other malignancies, and mortality risks following porphyria: A cohort study in Denmark and Sweden. Am J Epidem149:1010-1015, 1999.

Litman DA, Correia MA. L-tryptophan: A common denominator of biochemical and neurological events of acutehepatic porphyria. Science 222:1031, 1983.

Llewellyn DH, Kalsheker NA, Elder GH, Harrison PR, Chretien S, Goossens M. A MspI polymorphism for thehuman porphobilinogen deaminase gene. Nucleic Acids Res 15:1349, 1987.

Llewellyn D, Whatley S, Elder G. Acute intermittent porphyria caused by an arginine to histidine substitution (R26H)in the cofactor-binding cleft of porphobilinogen deaminase. Hum Mol Genet 2:1315-1316, 1993.

Llewellyn DH, Scobie GA, Urquhart AJ, Whatley SD, Roberts AG, Harrison PR, Elder GH. Acute intermittentporphyria caused by defective splicing of porphobilinogen deaminase RNA: a synonymous codon mutation at -22 bpfrom the 5' splice site causes skipping of exon 3. J Med Genet 33:437-438, 1996.

Louie GV, Brownlie PD, Lambert R, Cooper JB, Blundell TL, Wood SP, Warren MJ, Woodcock SC, Jordan PM.Structure of porphobilinogen deaminase reveals a flexible multidomain polymerase with a single catalytic site. Nature359:33-39, 1992.

Lundin G, Wedell A, Thunell S, Anvret M. Two new mutations in the porphobilinogen deaminase gene and ascreening method using PCR amplification of specific alleles. Hum Genet 93:59-62, 1994.

Lundin G, Hashemi J, Floderus Y, Thunell S, Sagen E, Lægreid A, Wassif W, Peters T, Anvret M. Four mutationsin the porphobilinogen deaminase gene in patients with acute intermittent porphyria. J Med Genet 32:979-981, 1995.

Lundin G, Anvret M. Characterization and regulation of the nonerythroid porphobilinogen deaminase promoter.Biohem Biophys Res Comm 231:409-411, 1997.

REFERENCES 74

Lundin G, Lee JS, Thunell S, Anvret M. Genetic investigation of the porphobilinogen deaminase gene in Swedishacute intermittent porphyria families. Hum Genet 100:63-66, 1997.

Macek MJ, Mercier B, Macková A, Miller PW, Hamosh A, Férec C, Cutting GR. Sensitivity of the denaturinggradient gel electrophoresis technique in detection of known mutations and novel Asian mutations in the CFTR gene.Hum Mutat 9:136-147, 1997.

Magnussen CR, Levine JB, Doherty JM, Cheeseman JO, Tschudy DP. A red cell enzyme method for the diagnosisof acute intermittent porphyria. Blood 44:857-868, 1974.

Makalowski W, Mitchell GA, Labuda D. Alu sequences in the coding regions of mRNA: a source for proteinvariability. Trends Genet 10:188-193, 1994.

Maquat LE. When cells stop making sense: effects of nonsense codons on RNA metabolism in vertebrate cells. RNA1:453-465, 1995.

Mauzerall D, Granick S. The occurrence and determination of delta-aminolevulinic acid and porphobilinogen inurine. J Biol Chem 219:435-436, 1956.

May B, Dogra S, Sadlon T, Bhasker C, Cox T, Bottomley S. Molecular regulation of heme biosynthesis in highervertebrates. Prog Nucleic Acid Res Mol Biol 51:1-51, 1995.

Meyer UA, Strand LJ, Doss M, Rees C, Marver HS. Intermittent acute porphyria - demonstration of genetic defectin porphobilinogen metabolism. New Engl J Med 286:1277-1282, 1972.

Mgone C, Lanyon W, Moore M, Connor J. Detection of seven point mutations in the porphobilinogen deaminasegene in patients with acute intermittent porphyria, by direct sequencing of in vitro amplified cDNA. Hum Genet90:12-16, 1992.

Mgone C, Lanyon W, Moore M, Louie G, Connor J. Detection of high mutation frequency in exon 12 of theporphobilinogen deaminase gene in patients with acute intermittent porphyria. Hum Genet 92:619-622, 1993.

Mgone C, Lanyon W, Moore M, Louie G, Connor J. Identification of five novel mutations in the porphobilinogendeaminase gene. Hum Mol Genet 3:809-811, 1994.

Michaud J, Brody LC, Steel G, Fontaine G, Martin LS, Valle D, Mitchell G. Strand-separating conformationalpolymorphism analysis: efficacy of detection of point mutations in the human ornithine δ-aminotransferase gene.Genomics 13:389-394, 1992.

Mignotte V, Wall L, deBoer E, Grosveld F, Romeo P-H. Two tissue-specific factors bind the erythroid promoter ofhuman porphobilinogen deaminase gene. Nucl Acids Res 17:37-54, 1989.

Miyagi K. Deficiency of hepatic porphobilinogen deaminase in acute intermittent porphyria. J, Kyushu Haematol Soc20:190-203, 1970.

Mohr CD, Stonsteby SK, Deretic V. The Pseudomonas aeruginosa homologs of hemC and hemD are linked to thegene encoding the regulator of mucoidy AlgR. Mol Gen Genet 242:177-184, 1994.

Moore MR, McColl KEL, Rimington C, Goldberg A. Disorders of porphyrin metabolism. Plenum PublishingCorporation, New York, 1987.

Moyret C, Theillet C, Puig PL, Molés J-P, Thomas G, Hamelin R. Relative efficiency of denaturing gradient gelelectrophoresis and single strand conformation polymorphism in the detection of mutations exons 5 to 8 of the p53gene. Oncogene 9:1739-1743, 1994.

Mullis KB, Faloona F. Specific synthesis of DNA in vitro via a polymerase-catalyzed chain reaction. MethodsEnzymol 155:335-350, 1987.

REFERENCES75

Mustafa S, Pabinger I, Mannhalter C. Protein S deficiency type I: identification of point mutations in 9 of 10families. Blood 86:3444-3451, 1995.

Mustajoki P, Koskelo P. Hereditary hepatic porphyrias in Finland. Acta Med Scand 200:171-178, 1976.

Mustajoki P. Normal erythrocyte uroporphyrinogen I synthase in a kindred with acute intermittent porphyria. AnnIntern Med 95:162-166, 1981.

Mustajoki P, Desnick RJ. Genetic heterogeneity in acute intermittent porphyria: characterization and frequency ofporphobilinogen deaminase in Finland. Brit Med J 291:505-509, 1985.

Mustajoki P, Kauppinen R, Lannfelt L, Koistinen J. Frequency of low porphobilinogen deaminase activity inFinland. J Intern Med 231:3889-3395, 1992.

Myers RM, Maniatis T, Lerman LS. Denaturation and localization of single base changes by denaturing gradient gelelectrophoresis. Methods Enzymol 155:501-527, 1987.

Nakai K, Sakamoto H. Construction of a novel database containing aberrant splicing mutations of mammalian genes.Gene 141:171-177, 1994.

Namba H, Narahara K, Tsuji K, Yokoyama Y, Seino Y. Assignment of human porphobilinogen deaminase to11q24.1 - q24.2 by in situ hybridization and gene dosage studies. Cytogenet Cell Genet 57:105-108, 1991.

Nishimura K, Taketani S, Inokuchi H. Cloning of a human cDNA for protoporphyrinogen oxidase bycomplementation in vivo of a hemG mutant of Escherichia coli. J Biol Chem 270:8076-8080, 1995.

Nissen H, Hansen AB, Guldberg P, Petersen NE, Larsen ML, Haghfelt T, Kristiansen K, Hørder M. Cellular andmolecular cardiology: Genetic diagnosis with the denaturing gel electrophoresis technique improves diagnosticprecision in familial hypercholesterolemia. Circulation 91:1641-1646, 1995.

Niwa M, MacDonald CC, Berget SM. Are vertebrate exons scanned during splice-site selection? Nature 360:277-280, 1992.

Nordmann Y, Puy H, da Silva V, Simonin S, Robreau AM, Bonaiti C, Phung LN, Deybach JC. Acute intermittentporphyria: prevalence of mutations in the porphobilinogen deaminase gene in blood donors in France. J Int Med242:213-217, 1997.

Ong PM, Lanyon WG, Hift RJ, Halkett J, Moore MR, Mgone CS, Connor JM. Detection of four mutations in sixunrelated patients with acute intermittent porphyria. Mol Cell Probe 10:57-61, 1996.

Ong PML, Lanyon WG, Graham G, Hift RJ, Halkett J, Moore MR, Connor JM. Acute intermittent porphyria: the invitro expression of mutant hydroxymethylbilane synthase. Mol Cell Probe 11:293-296, 1997.

Ong PM, Lanyon WG, Hift RJ, Halkett J, Cramp CE, Moore MR, Connor JM. Identification of two novel mutationsin the hydroxymethylbilane synthase gene in three patients from two unrelated families with acute intermittentporphyria. Hum Hered 48:24-29, 1998.

Orita M, Suzuki Y, Sekiya T, Hayashi K. Rapid and sensitive detection of point mutations and DNA polymorphismsusing the polymerase chain reaction. Genomics 5:874-879, 1989.

Peltz SW, He F, Welch E, Jacobson A. Nonsense-mediated decay in yeast. In: eds. Progress in Nucleic AcidsResearch and Molecular Biology. New York: Academic Press. pp. 271-298, 1994.

Petersen NE, Nissen H, Hansen TS, Rasmussen K, Brock A, Hørder M. R235X mutation in exon 15 of theporphobilinogen deaminase gene identified in two Danish families with acute intermittent porphyria. Clin Chem42:106-107, 1996.

REFERENCES 76

Petersen NE, Nissen H, Hørder M, Senz J, Jamani A, Schreiber WE. Mutation screening by denaturing gradient gelelectrophoresis in North American patients with acute intermittent porphyria. Clin Chem 44:1766-1768, 1998.

Petricek M, Rutberg L, Schroder I, Hederstedt L. Cloning and characterization of the hemA region of the Bacillussubtilis chromosome. J Bacteriol 172:2250-2258, 1990.

Picat C, Bourgeois F, Grandchamp B. PCR detection of a C/T polymorphism in exon 1 of the porphobilinogendeaminase gene (PBGD). Nucleic Acids Res 19:5099, 1991.

Ploos van Amstel JK, Bergman AJIW, van Beurden EACM, Roijers JFM, Peelen T, van der Berg IET, Poll-The BT,Kvittingen EA, Berger R. Hereditary tyrosinemia type 1: novel missense, nonsense and splice consensus mutationsin the human fumarylacetoacetate hydrolase gene variability of the genotype-phenotype relationship. Hum Genet97:51-59, 1996.

Proia R, D'Azzo A, Neufeld EF. Association of alfa- and beta-subunits during biosynthesis of beta-hexosaminidasein cultured fibroblasts. J Biol Chem 259:3350-3354, 1984.

Puy H, Deybach J-C, Robreau AM, Lamoril L, Nordmann Y. Detection of four novel mutations in theporphobilinogen deaminase gene in French Caucasian patients with acute intermittent porphyria. Hum Hered 46:177-180, 1996.

Puy H, Aquaron R, Lamoril J, Robreau AM, Nordmann Y, Deybach JC. Acute intermittent porphyria: rapidmolecular diagnosis. Cell Mol Biol 43:37-45, 1997a.

Puy H, Deybach J-C, Lamoril J, Robreau AM, Da Silva V, Gouya L, Grandchamp B, Nordmann Y. Molecularepidemiology and diagnosis of PBG deaminase gene defects in acute intermittent porphyria. Am J Hum Genet60:1373-1383, 1997b.

Puy H, Gross U, Deybach JC, Robreau AM, Frank M, Nordmann Y, Doss M. Exon 1 donor splice site mutations inthe porphobilinogen deaminase gene in the non-erythroid variant form of acute intermittent porphyria. Hum Genet103:570-575, 1998.

Raich N, Romeo PH, Dubart A, Beaupain D, Cohen-Solal M, Goossens M. Molecular cloning and complete primarysequence of human erythrocyte PBG deaminase. Nucleic Acids Res 14:5955-5968, 1986.

Rogers J. The origin and evolution of retroposons. Int Rev Cytol 93:187-279, 1985.

Rosipal R, Puy H, Lamoril J, Martasek P, Nordmann Y, Deybach JC. Molecular analysis of porphobilinogen (PBG)deaminase gene mutations in acute intermittent porphyria: first study in patients of Slavic origin. Scand J Clin LabInv 57:217-224, 1997.

Sambrook J, Fritsch EF, Maniatis T. Molecular cloning: A laboratory manual. In: eds. Cold Spring Harbor, NewYork: Cold Spring Harbor Laboratory Press. pp. 9.16-19.19, 1989.

Sanger F, Nicklen S, Coulson AR. DNA sequencing with chain-termination inhibitors. Proc Natl Acad Sci USA74:5463-5467, 1977.

Sassa S, Kappas A. Genetic, metabolic, and biochemical aspects of the porphyrias. In: Harris H, Hirschhorn K, eds.Advances in Human Genetics. New York: Plenum. pp. 121-231, 1981.

Schneider-Yin X, Bogard C, Rüfenacht UB, Puy H, Nordmann Y, Minder EI, Deybach J-C. Identification of aprevalent nonsense mutation (W283X) and two novel mutations in the porphobilinogen deaminase gene of Swisspatients with acute intermittent porphyria. Hum Hered in press, 1999.

Schreiber WE, Jamani A, Ritchie B. Detection of a T/C polymorphism in the porphobilinogen deaminase gene bypolymerase chain reaction amplification of specific alleles. Clin Chem 38:2153-2155, 1992.

REFERENCES77

Schreiber W, Fong F, Jamani A. Frameshift mutations in exons 9 and 10 of the porphobilinogen deaminase geneproduce a cross reacting immunological material (CRIM)-negative form of acute intermittent porphyria. Hum Genet93:552-556, 1994a.

Schreiber WE, Fong F, Jamani A. Molecular diagnosis of acute intermittent porphyria by analysis of DNA extractedfrom hair roots. Clin Chem 40:1744-1748, 1994b.

Schreiber WE, Rozon C, Fong F, Jamani A. Detection of polymorphisms and mutations in the porphobilinogendeaminase gene by nonisotopic SSCP. Clin Chem 40:1982-1983, 1994c.

Schreiber WE, Fong F, Nassar BA, Jamani A. Heteroduplex analysis detects frameshift and point mutations inpatients with acute intermittent porphyria. Hum Genet 96:161-166, 1995a.

Schreiber WE, Jamani A, Armstrong JG. Acute intermittent porphyria in a native North American family.Biochemical and molecular analysis. Am J Clin Pathol 103:730-734, 1995b.

Scobie G, Llewellyn D, Urquhart A, Smyth S, Kalsheker N, Harrison P, Elder G. Acute intermittent porphyria causedby a C-T mutation that produces a stop codon in the porphobilinogen deaminase gene. Hum Genet 85:631-634, 1990.

Sheffield VC, Cox DR, Lerman LS, Myers RM. Attachment of a 40 base G + C rich sequence (GC-clamp) togenomic DNA fragments by the polymerase chain reaction results in improved detection of single base changes. ProcNatl Acad Sci USA 86:232-236, 1989.

Shoolingin-Jordan PM. Porphobilinogen deaminase and uroporphyrinogen III synthase: structure, molecular biology,and mechanism. J Bioenerg Biomembr 27:181-195, 1995.

Simpson SB, Stolzfus CM. Frameshift mutations in the v-src gene of avian sarcoma virus act in cis to specificallyreduce v-src mRNA levels. Mol Cell Biol 14:1835-1844, 1994.

Stacey A, Schnieke A. SVpoly: a versatile mammalian expression vector. Nucleic Acids Res 18:2829, 1990.

Stein JA, Tschudy DP. Acute intermittent porphyria: A clinical and biochemical study of 46 patients. Medicine 49:1-16, 1970.

Syvänen A-C, Sajantila A, Lukka M. Identification of individuals by analysis of biallelic DNA markers using PCRand solid-phase minisequencing. Am J Hum Genet 52:46-59, 1993.

Thomas SD, Jordan PM. Nucleotide sequence of the hemC locus encoding porphobilinogen deaminase ofEscherichia coli K12. Nucleic Acid Res 14:6215-6226, 1986.

Toback AC, Sassa S, Poh-Fitzpatrick MB, Schechter J, Zaider E, Harber LC, Kappas A. Hepatoerythropoieticporphyria: Clinical, biochemical and enzymatic studies in a three-generation family lineage. N Engl J Med 316:645-650, 1987.

Tschudy DP, Valsamis M, Magnussen CR. Acute intermittent porphyria: Clinical and selected research aspects. AnnIntern Med 83:851, 1975.

Urlaub G, Mitchell PJ, Ciudad CJ, Chasin LA. Nonsense mutations in the dihydrofolate reductase gene affect RNAprocessing. Mol Cell Biol 9:2868-2880, 1989.

de Verneuil H, Aitken G, Nordmann Y. Familial and sporadic porphyria cutanea: Two different diseases. Hum Genet44:145-151, 1978.

Waldenström J. Studien über porphyrie. Acta Med Scand Suppl 82:1-254, 1937.

Waldenström J. The porphyrias as inborn errors of metabolism. Am J Med 22:758-773, 1957.

REFERENCES 78

Warren MJ, Jordan PM. Investigation into the nature of substrate binding to the dipyrromethane cofactor ofEscherichia coli porphobilinogen deaminase. Biochemistry 27:9020-9030, 1988.

Watson CJ, Schwartz S. Simple test for urinary porphobilinogen. Proc Soc Exp Biol Med 47:393-394, 1941.

Watson CJ, Pierach CA, Bossenmaier I, Cardinal R. Use of haematin in the acute attack of the "inducible" hepaticporphyrias. Adv Intern Med 23:265-285, 1978.

Wetterberg L. Akut intermittent porfyri. Läkartidningen 71:2461-2465, 1974.

Whatley SD, Woolf JR, Elder GH. Comparison of complementary and genomic DNA sequencing for the detectionof mutations in the HMBS gene in British patients with acute intermittent porphyria: identification of twenty fivenovel mutations. Hum Genet 104:505-510, 1999.

Woodcock SC, Jordan PM. Evidence for participation of aspartate-84 as a catalytic group at the active site ofporphobilinogen deaminase obtained by site-directed mutagenesis of the hemC gene from Escherichia coli.Biochemistry 33:2688-2695, 1994.

Yoo HW, Warner CA, Chen CH, Desnick RJ. Hydroxymethylbilane synthase: complete genomic sequence andamplifiable polymorphisms in the human gene. Genomics 15:21-29, 1993.

MOLECULAR GENETICS OF ACUTE INTERMITTENT PORPHYRIA · More detailed information about heme biosynthesis is available in the literature (e.g. Moore et al. 1987, Kappas et al. 1995)

Text of MOLECULAR GENETICS OF ACUTE INTERMITTENT PORPHYRIA · More detailed information about heme...

Acute intermittent porphyria case presentation

Ep European Porphyria Network...The European Porphyria Network’s (EPNET) mission is to improve the lives of porphyria patients by improving the diagnosis and treatment of these rare

Pompe disease Porphyria - A&I Online · intermittent porphyria is the most common and most severe form of acute porphyria, with symptomatic disease occurring in 1:10,000 to 1:20,000

Livingwithporphyria.eu | Acute Hepatic Porphyria

Cutanea Tarda Porphyria

Acute Intermittent Porphyria: Symptoms, Triggers, and ... · Acute Intermittent Porphyria: Symptoms, Triggers, and Other Factors Common symptoms of acute intermittent porphyria (AIP)

Porphyria: clinical presentations,diagnosis and treatmentsite-276408.mozfiles.com/files/276408/...WS2016_Acute_porphyria.pdf · Wouter Meersseman, MD, PhD Porphyria: clinical presentations,diagnosis

What is acute porphyria?

Porphyria · Porphyria Cutanea Tarda •Most common form of porphyria •Deficiency of uroporphyrinogen decarboxylase •Patients develop chronic blistering lesions on areas of the

Neurologic manifestations in porphyria

Heme Proteins, Heme Oxygenase-1 and Oxidative Stress

PTA Xi Theta Dinner Will Eta Kappas The Aid Mexican ... › archivednewspapers...MARCH 28, Wt PRESS-HERALD B-3 Xi Theta Dinner Will Eta Kappas Aid Mexican Orphans To Install Saturday

Porphyria - DermpathMD.com

A GUIDE FOR PEOPLE WITH PORPHYRIA - Retina · Web viewA GUIDE FOR PEOPLE WITH PORPHYRIA Thursday, 10 October 2002 This page left intentionally blank Index WHAT IS PORPHYRIA ? 1

Pilgerbroschüre "Via Porphyria"

THE REAL SIGMA KAPPAS · 2017. 10. 1. · The West Orange County Alumnae Chapter proves their growing sisterhood is genuine. THE REAL SIGMA KAPPAS OF ORANGE COUNTY In a place where

ACUTE PORPHYRIA WITH - dm5migu4zj3pb.cloudfront.netdm5migu4zj3pb.cloudfront.net/manuscripts/102000/102120/JCI4910212… · SODIUM AND CHLORIDE DEPLETION IN ACUTE PORPHYRIA WITH REFERENCE

Phi Sigma Kappas Jalopy

Metabolismo do Ferro. Importância Absorção Ingestão = ferro não heme e ferro heme Ingestão = ferro não heme e ferro heme O ferro inorgânico é absorvido

A Guide fosdsasdr People With Porphyria

Review Biosynthesis of heme in mammals · Porphyria cutanea tarda Variegate porphyria ALAD porphyria Erythropoietic porphyria 724 R.S. Ajioka et al. / Biochimica et Biophysica Acta

PORPHYRIA AWARENESS WEEK€¦ · PORPHYRIA AWARENESS WEEK APRIL 18-25, 2020 Porphyria Awareness week is an op-portunity for you to create awareness in your community! We strive to

ACUTE INTERMITTENT PORPHYRIA

Porphyria the vampire disease

Porphyria r (1)

STUDIES IN PORPHYRIA

dhruv porphyria

Case Report Feigning Acute Intermittent Porphyria

(including genetic testing) - Porphyria

Role of Heme and Heme-Proteins in Trypanosomatid Essential

Documents

MOLECULAR GENETICS OF ACUTE INTERMITTENT PORPHYRIA · More detailed information about heme biosynthesis is available in the literature (e.g. Moore et al. 1987, Kappas et al. 1995)

Text of MOLECULAR GENETICS OF ACUTE INTERMITTENT PORPHYRIA · More detailed information about heme...